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APPLICATION <br /> SAN JOAQUINJ�NbUNTY PUBLIC HEALTH SERVICES <br /> ENVIR ,`- <br /> � I�rVZLIU FIE L'TFI 5 R C 4 <br /> 445 N SAN JOAQiTi` 1 DivisJOM <br /> Y P O BOX 2009, ST ,: �� <br /> J <br /> PERMIT EgP ES 1 YEAR RO DATEIS-SUED IDY1L <br /> (Co ate ill Triplicate) ' <br /> Application is hereby made to Ba:n Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in eomplianoe with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address - S CityLot Size/Acreage .12Q X /!Sr� <br /> ' Owner's Name� _:DJC1C./- nt,�/' ' <br /> Address�� `.c-� . °Phone <br /> Contractor Addres - '�icens`e Nn. a�,�3 "'PhorTe' <br /> OF WELL/ P:..:. r NEW WELL-❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well Li <br /> PUMP-INSTAL-LATION'❑--f E '-SYSTEM-REPAIR G7• _ OTHER ❑ Monitoring Well <br /> DISTANCE 70 NEAREST; EPTIG TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> CA X 'FOUNDATION �W--AGRICULTURE WELL OTHERWWEL-12- PITS/SUMPS <br /> ENDED U5E f.TYPE OF:WK ELL PROBLEM AREA (CONSTRUCTION SPECIFICA;T.IOfJS =- _ <br /> L� I ustrial , ' ❑ Open-Bottom =- � ❑ Manteca + - <br /> _ Dia. of Well Excavation <br /> Par <br /> . Dia. of Well 'ng <br /> f7 rt tic/Private: a"f❑ Gravel Par ', ❑ Tracy Type of Casing_ '—' Y. t Spec fit <br /> (-I Other.. i .n Delta r t ` �"` <br /> i + —-..:., Type of t <br /> f I ork�) s; Approx. Depth t I Easter �I � nstt — k ` <br /> RerVa one ❑ r Type of Pump 4Amm-r "r <br /> � 3 r <br /> Well DiameteFDept i . � 37A p h ...r._ _.. _., <br /> 7 F TFC WORK'—NEIN iNSTACMION I I REPAIRlADDITION DESTRUCTION'I I INo septic system permitted;if pu s - <br /> available within 200 feet.} t <br /> fh Ila ' will serve: •Residence Commercial_� A ; <br /> � . Other r � i5 <br /> be ,fivi�g units:�_,.,r! Number of bedrooms <br /> a of=soil to a dopth of 3 feet: Water table depth <br /> �C TaAINKJr 15T.f] Type/Mfgl <br /> C `' <br /> apacity o. Compartments <br /> T�WTM�fJT-PSL-T. ❑ _;°1' .„,.. Method of Disposal <br /> s J <br /> =:z , Distance t l nearest: well Foundation p t <br /> i O',' -.. ■■ � party Line a <br /> ACHING LINE_A915�') No. & Length of lines f '� <br />' Total length/size ' <br /> �ILTER BED44'ii • Q, Distance to nearest: Well Foundation Property Line <br /> SEEPAGE_PITS/�C3rY K Depth e SFYB ! Lk Number "”' <br /> U0SUMPS u_ L! Distance to nearest: Well/ CA <br /> _1�V Foundation ?�f rPrvperty Line 1tJ�`f <br /> DISPOSAJNDS ❑ ; ]r <br /> I hereby certify that I have prepared this application an hat the work will be done 'n acc rdanc ' nces, sla a !a and <br /> rules and regulations of the San Joaquinl my IVAQWfN'C` � �' de d <br /> Home owner or licensed agent's_signature certifies the following: r , <br /> "I certitRi�l� �t�WINthis permit is issued, I shall not <br /> ' employ any person in such manner as to become subject to workman's compensation laws of alifornia."Contract nn <br /> g,pr'sub-contractin <br /> certifies the following: "I certify that in the performance of the work for whit 1 , , l { g signature' <br /> tion laws of California." ��� ��� ,a subject to rkman's co�mpensai <br /> The applicant must call far all required in pear ns. Cd rawing on reverse side. f <br /> Signed - .Title: <br /> —Date: <br /> FOR_DEPARTMENT E-QNUY-- <br /> Appticetn Accepted • Z9 Area' <br /> t <br /> or Grout Inspection byf Date r inal Inspection t5y Date <br /> AdditionalComments- <br /> .. <br /> . . . <br /> Applicant Return all copies to: San J quin County Public Health Services <br /> ~'4 Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> I _ . <br /> FEE AMOUNT DtJE AMOUNT REMITTED CK RECEIVED BY I INFO CASH DATE F_F_;Zs_, <br /> 'NO. <br /> EH 14-20 W <br /> r Ey 13.24(REV.1)K 5 ? +-fin' <br />