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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 h'77" Pi-1, <br /> (209) 468 4! <br /> -p <br /> -3447 <br /> PERNTT RYDTPR-Q I V-1 R <br /> (COmplete in Triplicate)"Mm MAY *'7L <br /> Application is hereby made to Sam Joaquin County f ENVIRONM <br /> APPliciLtion is made In cowliamcelvith San Joe, or a Permit to construct and/or install, <br /> Joaquin County Public Health Servi Joaquin County Ordinance 00, 549 and 1862 and J�J)iiAn This <br /> ea. Z99 a FRP <br /> *wpq. of Ban <br /> Job Address Size/Acreage <br /> A Owner's Name dress 14Lt�� <br /> • C nt <br /> Phone <br /> TYPE OFse No.4_(fyz�_,- Phone JW__ <br /> NEW WELL 0 WELL REPLACEME T M DESTRUCTION Cl Out of Service Well 0 <br /> PUMP INSTALLATION 0 SYSTEM REP OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK:— SEWER LINESDISPOSAL FLD.- PROP. LINE <br /> FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> -i--INTENDED USE TYPE OF WELIL.�;_ PROBLEM AREA - -CONSTRUCTION I <br /> M Vustrigi SP_ECIFICATIONS,,�- <br /> Open Bottom lym—anteca Die, of Well Excavation -4 <br /> ­'-wCaomestic/Private Dia, of Well Casing <br /> M Public C) Gravel Pack 0 Tracy Type of Casing <br /> V1 Other0 Delta specifications <br /> Depth of Grout Seal <br /> 0 irrigation (3 —Approx. D' h 0 rn Surface Saul Installed by Type of Grout, <br /> Mty <br /> Repair Work Done Type Of pump 4� <br /> H,P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material & Depth HHE�Zd�,�7 &: <br /> TYPE OF Depth Filler Material Depth <br /> SEPTIC NEW INSTALLATION jLJ REPAIR/ADDITION <br /> Ll I HUG I purl U I No septic system permitted <br /> Installation will serve: Residence— Commercial___� Other available within 200 fefti,j <br /> Number Of living Unit*: % - <br /> — Number of bedrooms <br /> Character of foil to a depth of 3 feet: A Water table depth <br /> SEPTIC TANK. 0 Type/Mfg ------- <br /> PKG. TREATMENT PLT. 0 Capacity„ No. Compartments, <br /> ..... Method of Disposal. <br /> public vver i <br /> Distance to nearest; Well Foundation_ Property Line <br /> LEACHING LINE I-) No. & Length of lines <br /> Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundations Property Line <br /> SEEPAGE PITS 11 Depth <br /> SUMPS -Size Number <br /> U Distance to nearest: Well <br /> DISPOSAL PONDS 0 Foundations Property Line <br /> I'hereby Certify that! have.ue <br /> I pared this application and that the v;brk'will be done in accordance willi Safi-jo�arq-6-i��- ;7 <br /> and <br /> rules and regulations of the San Joaquin county n co6-nVV <br /> Home owner or-licensed agent's signature Certifies the following: "I certify that in the performance of the work for which this P efmil is issued, I sho <br /> employ any person in such manner as to beco' <br /> Certifies the following: Irl C. me subject to 11 not 4 <br /> certify that in the pe fcr�m man's co�';P _�at'On liws Of California." Contractor's hiring or:sub-contracting signatuts <br /> lion Iowa Of Californla." performance of the work for which this permit is issued, I shall employ Persons subject to workman's compensa. <br /> Th Uzi c,#for/ZAII Z�110cl <br /> OquIrO J11spections, Complete evsrsJt?s1de'. <br /> 1 applx9us <br /> dra,;vingi on r <br /> Sicw;�� • <br /> Title. Date: <br /> FOR DEP FIT <br /> _E_NTU$A;0 N L Y <br /> Application Accepted by —v <br /> Date 44- Area <br /> Pit or Grout Inspection by <br /> Date, Final Inspection by <br /> Date <br /> Additional Comments, <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> FEE AMOUNT DUE 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> INFO AMOUNT REMITTED CK r CASH RECEIVED BY DATE MP,EAM17`NO, <br /> t d'a - <br /> E H 13-24[ACV,I/ kdj� <br /> EN A-M f 'A <br />