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APPLICATION <br /> 0 <br /> SAH ioAQLJIN COUNTY PUBLIC HEALTH <br /> E"I E[]NXENTAL BISALTS DIVISION <br /> �lr}�] <br /> 445 N SAN JOAQUIN, PHONE (209)46 4{{'�++ <br /> P 0 BOX 2009, STOCKTON, CA 95 # <br /> P <br /> (Complete in Triplicate) <br /> Application is hereby aade,t:o Sea Josquia County for it permit to Construct and/or ioat&ll the rwork herein described. This <br /> application to umde in compliance with San Soaquin County Ordinance So, 549 and 1862 and the Rules and Rar9QlAt1ens of San <br /> Joaquin cmwty, Pu'bl`ic Health servtcea. <br /> Job Address <br /> 0` .- �•�� - Crty Lot Si to/Acreage <br /> Owner. <br /> wner a Nmwne .—cxqdN- -y, r-� Addreta - Ph.,. 3 W3---' <br /> ContraCIor Cry-swe7LAddresS License No. ��7r'31 Phone <br /> TYPE OF WELLIPUMP NEW WELL C WELL REPLACEMENT Cl DESTRUCTION 0 out of service Well ❑ <br /> PUMP INSTALLATION C SYSTEM REPAIR Ll. OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRLICT1ON SPICiFICATIONS <br /> 0 Induatsial 0 Open Bottom ❑ Manteca Dia of Well Excavation Drs, of W" Casing <br /> Fl Domestic/plicate ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> 1'I Public f-1 Other 1-1 Del i it Depth of Grout Sea; Type <br /> e of s <br /> I I IrriDation --Apwox, Depth I I Eastern Surface Seal Insiaped by., -PAY- MINTni <br /> Repan Wark Clone 0 Type aI Rump H.P. -- State Work Done - <br /> Wefi Destruction 0 well Diameter Seting Itataria l i Depth <br /> Depth 71118ir flaterlal i Depth _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION A- REPAIR IADDITIQM I i DESTRUCTION I I INo MOI r+ <br /> .veil M <br /> lnsm"arion VAR marvel Ratidence!?�- Conv"rcrel_.._ Other_�� ENVIRONMENTAL HEALTH DIVISION <br /> N.mbrr of living units: --I-- Numbat of bedrooms:_ r <br /> Chtracfer of ao�to a depth of 3 Ines; �i�v't Watar table depth <br /> SEPTIC TANK J5. TypelMfg _r'+� Zyni-me Capachy I/1P-j;2— No, Cw-w <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest Well 4M' Foundation JQm.:_ Property Lina�_ <br /> Zo <br /> LEACHING LINE §r- No. b Length of linea _ r Total lanpttilsire V <br /> FILTER BED 0 Distance to newest: Well Founoalwn — Property Lina <br /> SEEPAGE PITS bL Depth a"� Sire � dumber . <br /> SUMPS LI Distance to nweisu Welt� Foundat an Proaarty Line <br /> DISPOSAL PONDS ❑ <br /> I tNreby tendy that I have prepared Chi[application and that the Work wilt be done in accoreance With San_loaquin county ordinanoes, .tate lays• and <br /> rules and raqulatsowm of the San JoaRwh County <br /> Horne owner or Gcord"agent'a signature Ixrlifira the following: "I cawtify that in ihe.pnfwmanC#of the work for which this perrrmt is issued. I shag not <br /> amploy any person in such msnnar as to become sublsct to wwkman'a Gornpenaalion taws of CakforAo Contractot's hiring or sub-contracting Signature <br /> Cartifiw the follov^ng:"I certify that in the perlormence of the Work for which this pormir 4 iuued. I shall employ persons subject to workman's cnrttpensa- <br /> xkm Iowa of Cant I? <br /> The applicant must Jf tk-e- Complete drawing on reverse tide. / <br /> Signed Title: 662An Date: <br /> FOR DEPARTIMIENT USE ONLY <br /> t <br /> AppMtatian Aceagted by Date Arra_� <br /> or Grout li4pection by 11ZIP alr� FhW Inspection by e.W5t 10-' <br /> Additkh ! Comments: <br /> Appltcant - Return all copies ta: San Joaqulo County Public Idealth Services <br /> Eaviraanentml Demuth Permit/aervican A u <br /> 445 N Sae Jo:gulls, P O Box 2049, Stkn, CA 95 Al /rj 1 <br /> 9FEE AMOUNTDVE AMOUNT REMITTED K RECErVEd BY D PERMIT Nig. <br /> . Ens iYt41aEV.i��ral <br /> EK 14 a1 I <br />