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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC IEdLVICES�; ,, <br /> ENV I P.ONYF3VT!'�I, IIEA.LTfi DIV <br /> �..���� <br /> 445 N SAN JOAQUIN, PHONE (40A� 3420 <br /> P 0 BOX 2009, STOCKTON, Ct(NI ' <br /> PEES �Y <br /> RMIT E%PIREAR FRO►! U3' 9 <br /> (Complete in Triplica1; <br /> VVV 11 lOc��� <br /> Appllcatloo Sa hereby made to San Joaquin County for i permit to construct and Ss <br /> application is ande is compliance v1th San Joaquin County Ordinance du. 549 and 11362 and the <br /> Joaquin County Public Health Services. <br /> i <br /> Job Address ��v —���N _ r''y - �N � SMC�e <br /> Owner's Nemo � address �H`• Paw <br /> Con Uaclor ���ACdressl�/�L License Ngv�Tf Phone <br /> TYPE OF WEAL/PU'MP: NEW WtLI :' WELL REPLACEMENT it DESTRUCTION O Out of Service Well 0 <br /> PUMP INSTALLATION C SYSTEM.REPAIR C OTHER O Monitoring Veil n <br /> DISTANCE TO NEAVST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 7 <br /> ^FOUNDATION AGRICULTURE WE..L OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLFM AREA CONSTRUCTION SPECIFICATIONS { <br /> 7 Industrial C Open Bonom C Manteca D's. of Wsll E.cevaton Out.of We"Casing <br /> %1 JJmestic/Priv.'rt C Grovel Pack C Tracy Type of(lung5eifvicaI"nnss�1 <br /> I'I "•.Jlk 71 Other (l Dela Depth of Grout !!@At ifl�aEN j <br /> 1 1 Irrigation _ Approx. Depth I ' Eastern Svrfaco Seul Installed by.-_ <br /> i Repair Wor; Done C Type of Pump H P. State Work Done_ <br /> Well Destruction C Wel;Diameter Sealing Material A Depth DEC .. <br /> Depth_ Filler Xistarial i Depth cAt�i ma Il IN COUNTY <br /> HYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION' DESTRUCTION I I INo sapl <br /> ,�atu61111µR N I <br /> :nstallation A+l!sera: Residence_ Comrrwrcial Other _ <br /> 1 Nvmbw of living units:-hLNumber of bodrnune— r <br /> YCharacter of ao9 to•depth of J feet: —Water L /W-ater table depth <br /> SEPTIC TANK Type/Mfg ��K L C pacify�� �.Compartments <br /> PKG. TREATMENT PLT.❑ / � Method of Disposal <br /> OWence to nearest: 1'311���-Founds tion�_ Property Line <br /> e LEACHING LINE 0 No.A Length ,: in- T tal length/sire <br /> FIL'ERX r Distance 10 r,;• Wou-� Foundalron fit;Property Lina <br /> 3 <br /> SEEPAGE?ITS if Dept-, — Si» Nun Vr. <br /> i SUMPS !_I D,trae to rso:rest: Wall__ Foundation •opony Line <br /> _. I <br /> 0ISPOSAI 'ONJS O <br /> {. I hataby certify that I have prepared this application and that'he work w,li be done M accordance with San Joaquin county ordinances,state laws,and f <br /> t rulas and regulations of the San Joaquin County i <br /> !' Home owner or licensed agent's signature certifies the following:"I certify that In the parforman,:e of the work for which this permit Is issued,1 oW not1L./ l <br /> i employ any person n such manner as to became subject to workman's compensation Laws of California."Contractor's hiring or sub-contracting YCnv.ire <br /> certifies the foaowmsg:"I certify that m the performance of the work for which lhls parntit is issued,I shall employ persons subject to workman's cornpenea• - t <br /> tion lave of CafNoltnia.- <br /> The applicant mu for an requ red. do . Compots rowing on r ids. f <br /> Dais: --2— <br /> Signed <br /> l�1 <br /> rtLa: <br /> � FOR DEPART T USE ONLY <br /> I c. .Z l <br /> Application Accepted by �"" ` *"" Date Area <br /> 24 <br /> Pit a psc <br /> Grout Inatksn by , Date Final Inspection by Date+-L� <br /> ... i Addhlonaf Comments: . <br /> t - <br /> Applicant - Return All copies to: San Joaquin County Public Health Servlr_ett <br /> govt re nano tel Health Pe Tint t/Sergi cse <br /> 415 H Sao Joaquin, P O Box 2009, titkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED- K- RtC(NEO sY DAT( ►EAMITNO. <br /> INFO CASH <br /> 3 C <br /> 1 I <br /> T 4�i>J,T,t.'Q'.ri:tir'VXif yk91r'. _ T ter•:,- rh - .. �.. �•;:.ti-i'an:tie„¢a:1�w., ._..•._.,..__ <br />