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APPLICATION FOR PERMIT <br /> SANVAQUIN COUNTY PUBLIC HEALTHRVI <br /> ENVIRONMENTAL HTSAIrTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (200468-342 <br /> P O BOX 2009, STOCKTON, CA 95201 JAN 3 0 1995 <br /> RERMIT EXPIRES YEAR R N DATE ISSUED <br /> (Complete in Triplicate) ENVIRONMENTAL HEALTH <br /> Application i■ here made to San Joaquin Count for UMIT, e n o'C�S <br /> Ayp by q y permit to construct and/or install the e e n ascribed. This <br /> ayplieatioa is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. I 1 <br /> Job Address 'l Zf'A45- T110ko K �OLtd City TGravrrTOl4Lot Sizc/Acreage <br /> [I <br /> Owner's Name Savb4vn D✓o.ke- Address 1315 AYv Phone A0 1-?57 -8679 <br /> &o 0 5W16,Wj,0 9.1b 736--t)-,T1 <br /> Gontractlx Address License No. iG __Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 out of Service Well ❑ <br /> i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER jk Monitoring Veli ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK µA SEWER LINES 14A DISPOSAL FLD. N4 a. PROP. LINE .NiA <br /> l FOUNDATION tJOr AGRICULTURE WELL OTHER WELL hL& PITS/SUMPS hm- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTAUC.T1A--nrw-IFICATIONS <br /> I.S ire. <br /> M Industtiel ❑ Open Bottom _. _ -, $i k. #iikY Z.5 enc s Dia, of Well Casing <br /> [.1 Domestic/Primate ❑ Grav :s z ;`t #s, r _ .�'l Specifications <br /> 1';1 Public Otl+e "�.t? w ;" ti . 15:C+. Type of Grout w- nee►' <br /> I I IrrigationEI 1S#. Ap C -1 SES Caws«h 7 wry <br /> o� <br /> Repair Work Done 0 Type of _ u .. " ..� we Work Done _ <br /> T WOU Destruction ❑ Well Dial <br /> I Depth14 - t <br /> TYPE OF SEPTIC WORK; NEW IN 0- .- <br /> A.,5 t ti l +� w w .1 1 1No septic system permilled if public sewer is <br /> [dsse no}aAPly) available within 200 leet.l <br /> Installation tWl serve: Residence". A, <br /> Number of living units. NL <br /> Character of sol to a depth of 3 fee . _ • Water table depth <br /> SEPTIC TANK. O Type/NO "W ', *� No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance W- Property Line <br /> LEACHING LINE 0 No. b Le c'►; .4 � � , ~. � w Jngth/size <br /> FILTER BED j ❑ Distance r o` `Property Line <br /> (does no}APp14 y.--- -- ' <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ c1 ons HQ} akipel <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or IiGnsed agent's signature cenifiH the following: "i Certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person m such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following:"I canity that in the performance of the work for which[hie permit is issued, I Shell employ persons subject to workman's compensa- <br /> tion laws of California." <br /> Theft' Acicapted <br /> st for w lions�r Complete drawing on reverse side. <br /> Sig Title: rTo_ttG7 _ �jllCl4firf� Date: L/�7L• '! S <br /> FOR DEPARTMENT USE ONLY <br /> Apby Date Afee <br /> d <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> f Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2008, Stkn, CA 95201 <br /> IINFD FEE AMOUNT DUE AMOUNT REMITTED CASH CK A RECEIVED by DATE PERMIT NO, <br /> i <br /> . EM 11N INEV.v_e sr <br /> fM WX <br /> �i <br />