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APPLICATION F01( Ph'11I41T <br /> I;ANdUAQUIN COUNTY P1JTiLtt.'• HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I� e� �Q1�A�I ENfr, 1601 E. IlA'LELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTGN, CA 95201 p <br /> Pk;IWIT EXPIIlI"s5 1 YEAI( 1,',8,21{ DATE ISSUED <br /> (Complete in Triplicate) <br /> Application to hereby sade,to San Joaquin County for a prire.lt to construct and/or install the work herein descrlbcri. Thls <br /> apollcation to aade in costplianco with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulation* or "I n <br /> Joaquin County Public Health Services. <br /> Job Addres,tf _ _ s� Acreage�t Size/ <br /> tic ✓ <br /> Owner's Name_ 1"a no LCl/i0— Addrats _���_—L�.__ LCL LLQ � Phone Z�3 7 _ <br /> Contiatior�l_� 5 '_.---Addie<:. Y �5.E-(,_!;1'r -40' _License No _a �Xi� Phone 7Y�-zzlJ <br /> TYPE OF WELL/PUMP NEW WELL 1V WELL REPLACEMENT V DESTRUCTION : Out of Service Well Ll <br /> PUMP INSTALLATION Q SYSTEM REPAIR i:1 -OTHER ❑ Monivringwell 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE1 LINES �_ DISPOSAL FLO. "- PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 1s�_ OTHER WELL PITS/SUMPS <br /> INTENDED USE TvpE OF WELL PROBLEM AREA CO_N5Tilt_UCTION SPECIFICATIONS , <br /> (1 Industrial Open Donor C1 Manteca Ora of WON Eacoval on_20 Dim o1 Well Car <br /> mey _ <br /> f I DosticrPrlvate (_l Gravel Pack I 1 Tracy Two of Casrnp. N3rosa _ Spo'n6cahons <br /> I'I P bite I 1 Other I I Delta Oopih of Grow Seat _�j-V' Type of Grout <br /> I rrgjrtroh f:i � Approa Dapth I I Eastern Surface Real insiavted by <br /> Repair Work Done U Type of Pump __ H P StatsWor Oats _ lw <br /> Woo Destruction fid Well Diameter _ 12 r Sealing ►4terial 6 Depth_�:t <br /> Depth <br /> Filler Material k Depth •*r - j T\ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR I ADDITION 17 L1ESiRUCTiON I I INo septic system permltlW if puWrc sewer is <br /> available valhin 2W fesl.l (� <br /> InstaHstion well serve: kfence _.._ Commercial, Other <br /> Numbs of Wing units. __ be•of bedrooms <br /> Chiracta of soil to.depth of 3 lost: . <br /> SEPTIC TANK O Type/06411i Capacity__ ompannrnte <br /> C1 i0 <br /> PKG. TREATMENT PLT, � � <br /> Cr <br /> DisUnca to carni: Well _ Property line (a <br /> LEACHING LINE LI No. A Lengill of t. _�_� _ _�� Tois /site <br /> FILTER BED 0Dutane rte Weil Foundation __ Proper <br /> SEEPAGE PITS I Depth Numbs <br /> SUMPS _e" 1.1 Dwane&to nearest: Well Foundation Property Luse_ t <br /> DISPOSAL PONDS (l <br /> I hereby certify that t have pleperod this applKshon and that the work will(re dons in accordance with SM Joaquin county ordinances,slate laws, ar�( <br /> rubs and ragutatrons of the Sin Joaquin County <br /> Home owner or licensed aftenta aignsitas%;wwos the following "I ctrt.ty that in the performance of the work for which this parnrt is Issued. I shah not <br /> smpiov any Ween In such manner as to become subject In workman's con,pnution jaws of Cabforrwa"Contractor's hiring or subcontracting signatwo <br /> Conl1wo IM following "I certify that in to performance of the work for which this pernul Is issued.I ensu omplOy persons subject to workmerY&compenu <br /> Ilan laws of Cafifanis" <br /> The applicant mus all for an require)inspections Compete draw"on rsvefae aide. <br /> Signed x C'� -. «� T.I. ---- 01111C �/ <br /> fl/1- • f0.\,`\�►OIVARTMENT USk ONLY <br /> Application Accepted by __ . .r.,a4-tl'mt...c.-COate�t.-n t L.�__ Mea <br /> Pit a Grout IMOP4Ctron by <br /> �y� J�«✓.-t C� Dave j,C��- Final Inspection by_ Date <br /> Additional Comrnanta <br /> Applicant - Roturn all cwtee tr•t Ban Joayuln County Publtc Health <br /> Sorvir'os, rrivironmentA1 Health Persalt/Services <br /> 1601 Z. fsasoltrn Ave., P 0 Lfoa 2009. Stockton, CA 95201 <br /> �Ff -1 A^MOUNT 00 .'Abr1(NT he M-ttlDI _Ch�f hLCkMD fly DAT( PERMIT N0. 1 <br />