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APPLICATION FOR Pr.'RMIT <br /> SAN JOAQUIN COL`NTY PUBLIC HEALTH SERVICEiS <br /> ENVIRONNFUTAL IIEAI.Tif DIVISION <br /> 11561 E. 11AZELTON AVF,. , PHUNI: (209)468--3420 <br /> P O BOX -90U9, S':'(1C1;1'Lh, CA 95201 <br /> JUA IT Y I'IItES I YF°yH FROM DATE ls=U 2 <br /> (Complete it. Triplicate) <br /> Appl:eatiun is hereby made•to San JoAquin County for a prrmlt, t� cor•ntruc and/cr tr.s'aLl the work herein described. T`ts <br /> application is seeds in compliance vivo San Joaquin County Ordinance 4o. '•i and 1862 and the Rules and Regulations of Sen <br /> Josgjia County Public Health Servicer r7 <br /> JoU Address C, S.-?5..._!'-vJ _.�_.__..� C-tee/-U�!�____ Wt daze/Acrenfe - <br /> Owner's Name_� .�bf1L_ Address1�J__ Phone <br /> Contractor P Aoerrss LIL'e�.e NeaC't5�^ <br /> TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT f i DESTRUCTION Cl Out a. Service Well Ll <br /> PUM'INSTALLATION " SYSTEM RCPAtR OTHER !:, '4mitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK __ SEWER LINES _ -- DISPOSAL FLO. PPO- '_,NE <br /> FOUNDATION____ AGRICULTURE WELL _ _ OTHER WELL. _ PIT_- SL.'APS _ <br /> INTENOED USF TYPE OF WELL Pr,ORLEMAREA CONSTRUCTION SPECIFICATIONS <br /> ('I Industnal U Open Bottom C)Manteca Ora of Well Excavation Da.of Well Casing <br /> I I Domestic I Fir vote 0 Gravel Pack C, Tracy Tspe of Carng__—__ SpecdrraCons -.- <br /> I"I;subho I I other ;'i Della Depth of Grout Seal _-._-___-_ Type of Gros- <br /> l-1 I Irrrgatlon ,.._Auleox.Depth I I Eastern Surtace Seel Installed by <br /> Repair Work Done U Type of Pump - _ h P. State Work Done <br /> Well Destruction LI Well Diameter Sealing lYter.<wl i berth ,- <br /> Depth Tiller Materiel i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/AUDITION(/• DESTRU-.TION I 1 INo septic system permrrtad r'onblre saw*(H <br /> avadable wdMn 200 feet.) <br /> Installation will so". i`esidence v Commercial— Other <br /> Numt7er of being units:-�- Number of r191owm/},I1 <br /> - <br /> Character of soil to a dept's of 0 lest: -CeCast�'.�._.-- --------------Water tabb depth �O .r <br /> SEPTIC TANK ❑ Type/Mfg —_ Caparay----_ No.Cornoartments <br /> PKG.TLEATMENT PLT.❑ Method of Disposal <br /> O,ttance to nearest: Well Foundoton P.oveny line <br /> LEACHING UNE Lo'No. S Length of fines J�_( _ d�7 Tow Ienythh:7a� Q <br /> FILTER BED 0 D.stsnce to nosiest: Wsllp _ Foundation Ppeny Lee.. F <br /> i�� w <br /> k <br /> SEEPAGE PITS fY Depth J_4 ,__.____ Number <br /> SUMPS l 1 Distance to nearest: Well __ Foundanon _..�Q�- Properly Line__Uf—s l <br /> DISPOSAL PONDS El <br /> 1 hereby certi y that I have prepared this appl cat or and that:he work wdl Le done in accordance^,Ih San Joaquin county ordinances,slate laws,and <br /> rules and regulations of the San Joaquin County <br /> Home overlieorlicensed agent's PgMtuto coindKs the following. "I cerlth 14sf In the perlofrnanre of the work lot which this permit is Issued.1 shalt not <br /> employ any person in such manner as to become wbje:t Ica wo(kmAn's zompansation taws of Caldorroa-Contractor's hiring or subcontracting signature <br /> Candles the foaowrng:"I certify that M the performance of the rrbrt for wh•^.h d•Is pernut is rssucd,1 snail employ parson*subject to wof"n'a tompen". •;(' <br /> tion laws of California." <br /> The oppl•ean I'll rogue visa Iron*. Comooto drawing on, sew soa <br /> Signed M-,: __ Tltk:— C��2Gr ---- --- Date: I _ <br /> FOR DEPARTMENT USE ONLY <br /> Appliutton Accepted by ,` �! // _ Data �— _ Area <br /> Pi or Grout Inspection by ^` ACL D est Inspection by �' ofs <br /> AOd te7M1 Commence: '-�. (rL (i-I I-!✓✓� �� / i I o s ^ [Sr a .71^�b- Ye T N _ <br /> Applicant - Return all copies ta.: San Joaquin Count: Public Health <br /> Services, LnYironawnt.-1 Health Fermlt!Services <br /> 1601 Z. Haselt.w Ave., P ') sox ?609, Stccxton, CA 95201 <br /> AMpuNT DUE AMOUNT R[MltTlp C �� RECErv[p®Y PATE F:NMfI N0. <br /> .lh ti7e u[v r..s.St Il` <br />