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Y <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PLITIi,IC HEALTH I=F.RVICFS <br /> "V I ROWWrAi, RHALT11 I)M S I ON <br /> 7( k l 1• 1601 F. IIA2FLTON AVE. , I IIUNE: (209)468-3A20 <br /> P U BOX 2009, S1'()CKT(JIN, CA 95201 <br /> P1;_RJf1T EXf'LR�s�'_LYBAB FR)N rDATB ISSU® <br /> (Complete in Triplicate) <br /> Applicatt,r. is ^ avid! to Sac Josgain County for a perxt' to construct andlor Install the work herein described. This <br /> application ie rare In cAwliance with San Josguin Ceunty Ordirm.-e No. 549 *rJ.1862jand the Rules atsd Regulations of San <br /> Joaquin County rublic Health Serviee <br /> Lot Size/Acreag <br /> Job Address ../i1 •. -_.J ----r--�-�`--=��./Y..�'-C_.---__ C'Tv----- - moi, ( �7 <br /> Phone <br /> Owner's Name <br /> -{ �� . 7�C •_�,_ -� eis 'L G_�- / ��C_I�.�-ft'sL�c"t. ^1a.��I.-��Pnone�J���- <br /> Cert'ictor {• `'�`- �� ell C <br /> TyPE OF WELL c'Lti•p NEW WEe _ VoEll FEptACE-*F%' DESTRUCTION 1' Out of Brri g Well LZ <br /> -------------- PUMP INSTALLATION 7 SYSTftit REPAIR :. OTHER :' irlon t efor t ttg <br /> DISPOSALFLO PROP LINE _-_ <br /> DIS'ANCE TO NEAREST SEPTIC TANK SE.I'ER LINES - PITSISUMPS <br /> FOUNDATION _ AGRICULTURE WELL OTHER WSLL �\ <br /> INTENDED USE _ TYPE OF WELL PROBLEMARF A CONSTRUCT.,IN_S_PECIFICATIONS <br /> -- Manteca D,a of WeH Excavation _- -__-- Dra nl WeN Casing l <br /> Indus!,-a'- -.--- ''Open Bottom Specifications ---- <br /> Ddus!,-c Pn.ate Gravel Pack Tracy Tvpe of Casing- _ <br /> Delia Depth of Grout Seal - ---. Type of Grout <br /> Puhl•t .' Otne+ _ <br /> blAPlvel Depth I I Eastern Surface Seer Installed by ____ --- <br /> non <br /> Report Work Dore Type of Pump _. H P. State Work pone <br /> — �--- <br /> Sealing Material i Depth <br /> Well Oestructron Wal!Diameter Filler Material i Depth <br /> Depth _ <br /> TYPE OF SEPTIC WORK NEW INSTAI LATION REPAIR ADDITION , DESTRUCTION I i a4C e'w,stithin-1 Iremettled d Public sewer a <br /> t <br /> Installation will serve Rasldence _(._ Commercial_ Other ,- <br /> Number of hump units Number of bedrtwms_jo / -^y - - <br /> 't��r's"1W,/ �y Water table depth <br /> Character of soli IO a depth o}3 feat' <br /> SEPTIC TANK i i TVpslMlp �_ Capacrty1�1 No.Compartments <br /> PKG. TREATMENT PLT Method of Dlsprna <br /> � <br /> Distance to nearest' We" .0�_ !FOundatron_;ZA .___- Progeny Line C <br /> I NOTHING LINE . No.g Length of lines .- - - _ <br /> cILTEP HED Distance to nearest. Won ���.' Foundation-� Propervv Lina <br /> SEEPAGE P!TS <br /> UMP Distance to M"fost. WeH.� d Foundation�`(.. Plepenie I. <br /> ISPOSAL PONOS <br /> I hereby caddy Ina! I nave Prepared this application and that the work will be dune n accordance iii-In San Joaquin county ordinances.state taws.and <br /> rules end ragulet-ons of the San Josqu,n County <br /> Home uwnar or o,ensed agimr'a Signature centiles the loffowlng I certdy that m Ina aws onance o1 the work for which this ring of Sub-t O rasWd,I Mal ut not <br /> Cemploy emfresthe following,low ng.s'Ih mannot as to certifythat n the paA�manca of lublfct the workafor hich this Permit i$Sued.I shall employ peoeonslsubject o workman's 9C rornpensa <br /> ..on laws of California- <br /> The aPPllcanl piusl all to MI requl wisecl•ons Comoeto drawing or p �-,@is@ side / <br /> �} �i� LG6-- Title �L--�f�-------- Dete' -L-�-- <br /> Srgned X <br /> FOR DEPARTMENT USE ONLY /� <br /> Date( ���t✓ Area <br /> Appllcanon,4cc, Iia by / --�-- -- <br /> c t <br /> =' � t?'/ Date/Z--/_1 c _ Final Inspection by Deu/� __j0 <br /> Pit or Grout Inon by }-.G '� <br /> Addwon,d Comments -- /--- <br /> Applicant - Return all copies to: Sign Services. <br /> EEnvionmenttaltHealthHealth <br /> Peralt/Servlees <br /> 1b01 E. Hazelton Ave., P 0 Box 2009. Stockton. CA 95201 <br /> CK RECEIVED ey DATE ►ERIMSI1 NO <br /> I NfO <br /> 1"I AMOUNT DUE^ AM`OU4T REMITTED CASH IZ1 ����-� <br />