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APPLICATION FOR PERMIT
<br />SAN JOAQUIN C0UNTY, PUBLIC RRALTR SERVICES
<br />ENVIRONMENTAL BRAINS DIVISION
<br />445 N SAN JOAQUIN, PBONE,(209)468-3420
<br />P 0 BOX 2009, STOCKTON, CA 95201
<br />PERMIT EXPIRES 1 laAR nom PATE ISSUED
<br />' (Complete-in Triplicate)
<br />Applicant - Return all cop : San joaquit1 County Public Health Services ''-ttrolreamental Health PermIt/Servicee
<br />445 N San Joaquin. P 0 pox 2000. Stan, CA 95201
<br />Application is hereby mule co San Joaquin Cotuaty for a perstit. to construct and/or
<br />asrplication in made ix corPliance with San Joaquin Couraty Ordinsty,p No. 549 and 1
<br />Joaquin County Public Health Services. co - 04r7 60 - 7
<br />e
<br />tall tlin -work herein described. This
<br />and the Roles and Regulations of San
<br />tz.e
<br />Lot Sise/Acr e ./-5-4C '
<br />. 1 ,
<br />"1;6. Address '0 .R19_V- 3 75 -1- /2A I ,' .1/ - i\ -72 Owners Name .1..) 4 P
<br />' .
<br />.„ i Contract.. ' Nib Address - 6 44 4.9.-----(2)---/T. LiE.enii ti'-ti S. Phone Z6,51977
<br />;TYPE OF WELLIPUMP',. NEW WELL WELL PEPLACEM€NTY‹ DESTRUCTION 0 Out of Service Well', p
<br />6
<br />4
<br />PUMP INSTALUI'iTION ' ' • SYSTEM REPAIR 0 ' ' - OTHER 0 SmitGrIng WeP" i
<br />!DISTANCE TO NEAREST: SEPTIC TANK An it SEWER LINES DISPOSAL FLD. PROP. 'CINE-
<br />FOUNDATION ? AGRICULTURE WELL OTHER WELL PITS/SUMPS —
<br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF S
<br />Xlrioustriel 0 Open flottorn 0 Manteca Dia. of Well Excavation Dia. of Well Casing .
<br />n Domestic'/Private >4, Graver Pack. I 0 Tracy Type of Casing > i 'L Specifications
<br />Public 1A 0 Opts 8- n Delta Depth of Grout Seal Ty or Grout
<br />.(1rrigarion ...ig-l2... Approx, Depth l Eastern , Surface Seel Installed by Va lie .si rN 0.1 ) 'a 'e•-•
<br />*pair Work Done 0 Type of Pump H.P./--S"- State Work Dons Sort-
<br />WO Destruction 0 Welt Diameter Sealing Material a Depth -‘..., , .
<br />!, Piller Naterial a Depth . _ .. . '' ' ----%•-• •''''i Depth
<br />,
<br />, --...
<br />TYPE OFSEPTIC WORK: NEW INSTALLATION I I RERAIRJAIDOITION I I . DESTRUCTION I i.fhlo septic system permitter/ i public sewer is,
<br />
<br />- ...- , available within 200 feat.) . ...
<br />1
<br />‘,
<br />Meta/Onion will serve: Residence _ .Consherciel Other i , !
<br />! Number of living units: Number' Of bedrooms . ,
<br />Character of sod to a &PIN of 3 feet: . ' Water! table depth ,
<br />SEPTIC TANK 0 Type/Mfg • ".• ' ' , Capacity No. Compartments- 1 PKG. TREATMENT PLT. 0 1 Minfaxt of Disposal '
<br />, Distance to nested
<br />,
<br />: Well , Foundation Property Line ., .... . .„
<br />LEACHING LINE 0 No. & Length of lines Total length/NU .
<br />i FILTER BED i 0 Distance to nearest: . Well Foundation Property Line ? ,.
<br />SEEPAGE PITS I I Depth 1 Size Number .
<br />;,,, _ SUMPS . LI Distance to nearest: Well Foundation Property Line . . • - ,
<br />DISPOSAL PONDS 0 ,
<br />hereby canity that I have prepared this ippliatiori-ind 'Oat 'the work willbe done in accordance with San Joaquin county ordinances, state laws, and
<br />rules and regulations of the San Joaquin County
<br />Horne owner Or licensed agent's signature certifies this following: "I certify that in the performance or the Work for which this permit is issued, I shall not
<br />employ any person in auch manner as to become subject to workmen's compenserion taws of California," Contractors hiring or sub-contracting signature
<br />certifies the following: "I certify that in this performance of the work for *Mich this permit is issued, I shall employ persons subject to workman's compensa-
<br />tion laws Of California."
<br />The apparent must call for
<br />Application Accepted by
<br />phi+ InflPeCtien by
<br />awing on reverse side.
<br />Title: ii
<br />DEPARTMENT USE ONLY
<br />Date g '244-
<br />u, 7-1 Fins/ inspection
<br />Area • -2)-
<br />AMOUNT OtJE ,! AMOUNT8EMITTEO E , ..
<br />DATE PEAMIT'NO.
<br />/3 41 l'6 1 I .7) 0 aZI P / ( I . I.,
<br />OLT71
<br />43 ,-' fi 3-7)
<br />0
<br />. Iii1344 rary. -its 5)
<br />Its 14.al
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