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APPLICATION FOR PE U �� <br /> SAN JOAQUIN COETMW PUBLIC , <br /> ENVIRONMENTAL HEALTH D <br /> 445 N SAN JOAQUIN, PHONE <br /> P O BOX 2009, STOCKTON, C�A5�1 <br /> _ div <br /> ]!EMIT T EXP I RES 1 YEAR FROM DAT&I ISSU l �N(� 44 05f <br /> (Complete in Triplicate) <br /> Application is hereby avule to Baa Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is aide in corpliance with Ban Joaquin County Ordintwce No. 549 and 1962 and the Rules AM Refyu"ticna of Baa <br /> Joaquin County Pudic Healt:b Ser+rices. <br /> �City Ti Lot Site/Acrevse � $� <br /> Job Address �7 <br /> Owner's Name :-`t.�l GiOLL L- I Address Phone 0 r <br /> Conitaclbr )uL ,( \�� "' / Address �� f License No. 0 <br /> TYPE OF WELL/PUMP: nIEW WELL Q WELL REPLACEMENT Cl DESTRUCTION O Out of Service Yell <br /> PUMP INSTALLATION 0 SYSTEM REPAIR O OTHER Cl 1lonitoarins Yell 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION , AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ((1 <br /> Cl Industnal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia.of Well Casing <br /> C1 ocimeatic/Private D Grp" Pack D Tracy Typo of Casing__ Specifications <br /> I"1 Public Il Other n Dom Depth of Grout Seal Typo of Grout df <br /> I i Iniyation ____Approx. Depth I I Eastern Surface Seal Inslatiod by <br /> Repair Work Dons L3 Type of Pump H.P. Stare Work Done <br /> War Destruction ❑ Well Diertetar Sea=ms Material i Depth <br /> Depth Filler Material 1. Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDIT!ON I I DESTRUCTION 11 (No septic system pormated if public awvw is <br /> evplable within 2W lest.1 <br /> InataNS On VA esrve: Rakienco__,_ Commercial K Other <br /> NumDar of living units: Number of bed ma <br /> / <br /> Charocsor of soil to a depth of 3 tow 72 Water table depth r!. <br /> SEPTIC TANK �Typs/M1g � CapWAY '� m <br /> No. Compntants <br /> PKG. TREATMENT PL .0 I I Method of 0*)0 1 <br /> Distance to nearest: WON , n� FoundationL _ Property Line <br /> LEACHING LINE No. 6 f..Ongth of Iires I C TStN longth/si:a <br /> FILTER SED (D Distance to nweet. WON— Foundation, _''_ Propenv Lina S r f <br /> r rr <br /> SEEPAGE PITS Depth S Sirs Number <br /> r r <br /> SUMPS 11 Oita <br /> snp to rtse.Oet: W.II Foundation /L�' '� Pr <br /> oFwty line v�S� <br /> DISPOSAL PONDS O <br /> I horeby cortify that I have prepared thla Vpkcation and that the work will be done in accordance with San Jo4quin county ordinances, stags laws, and <br /> Fula and requisitions of the Sen Joaquin County <br /> Mon»owner or biwtMd agent's.ignecure certifies the following: "I certify that in the performance of the work for which this permit is issued, 1"not <br /> an+PbY"Person in such manner.,a to become subject to workman's compensation laws of California." Contractor's hiring or sub-wntractinq signature <br /> certifies the following: "I certify th.t in the performance of the work for which this permit is issued,I shall employ ponkw s subject to wockman'a cnntpensa- <br /> dors Ince of Cawarnila." <br /> The cam fnr r ad inapections. Compote drawing on reverse side `�' <br /> SignILc mb� <br /> ed ``l�.d ��''``1 Tito: \/r ` _ OOte: _ <br /> FOA DEPARTMENT USE ONLY <br /> Applicaebm Accepted by Aeta � � Arse rZ 1 <br /> of Grout Orout Irnpactlwi by Date Finsi Inspection by Date�i J <br /> AddhbnM Comm onto: IL <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environa.ental Health Permit/8ervicee <br /> 445 N Ban Joaquin, P 0 Box 7008, Stkn, CA 95201 O O V/t Q�� <br /> .+ FEE AMOUNT otrE AMOUNT REMITTED N IIECErvio ■Y 0 ►ERMtt7'N0. v <br /> FO <br /> �� 1 ` f / <br /> /Al,r//v}�') <br /> • IM 14s IeLM. i sr N ,! <br />