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• APPLICATION FOR PEMIT <br /> SAN JOA4 VIN COUNTY PUBLIC HEALTH S$ ICSS <br /> ENVIROMIMTAL HEALTH DIVISION <br /> 1601 X. IAZSLTON AVS. . PHONE (209)468-8420 <br /> P 0 BOX 2009, STOCITON, CA 95201 <br /> (Complete its TrlplLeat:e) <br /> Application is hereby as4e,to aa* Joaquin County for a posit to construct and/or inetaU the trorlt beret* described. This <br /> applioatlon i■ wade in catolsance vitit San Joaquin County Ordinance Mo. 549 and 1662 OA& tha Rulas and begtlattone of San <br /> Joaquin County Pub"a Health Services. <br /> Job Address 770Y As city ak bn .I Lot Mise/Acreage <br /> p tr,►� an .S k.Wet" 958x? P 4L6 <br /> Ownar's Name % +T• Address <br /> • 1}D9 l..c�tni 14,q2_3'7014,q2_3'7014,q2_3'70�7 1 <br /> ConUsctor Address omd License No. 3'70 _ pho <br /> TYPE OF WELL/P : EW WELL © WELL REPLACEMENT C3 DESTRUCTION I7 Out of 8ervics well U <br /> PUMP INSTALLATIO O SYSTEM REPAIR O •-OTHER KV4. al r � L7 <br /> or <br /> DISTANCE TO NEAREST: SEPTIC YANK SEWER LINES DISPOSAL A.D. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL,. PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROOLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L3 Industrial ❑ Open Bonttrlt. 0 Mangy toga Dia. of Was Eacavation DIA. of WON Ca <br /> ssoxL <br /> Cl Domestic/Prlvals g Gravel Pack ❑ Tracy Typo of Casing Specifications QLM <br /> I'I Publlc 13 other f 1 wits Depth of Grout Seale Type of Orou W <br /> I I Iniystion ...,...Approx. Depth I I Eastern SwIsce Serf Installed byr` <br /> Repair Work Dons D Type of Pump .. H.P. - I#= <br /> Well Destruction Q WON Dlrrator SOLUM4 Materiel 4 Depth <br /> cvwr n Depth Filler Itaterial 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INa saplie sysism permitied if public sewer is <br /> ovailable within 200 1"1.1 <br /> Installation will @am.* Residence. ConwtarcW_ 0111ar,,....._....� <br /> Number of living wrier- Number of bedrooms.,,..�.•.,..,,.. <br /> Character of loll to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. L] Typo/Mfg Capacity No. Contpar~ts <br /> PKG.TREATMENT PLT.E) Method of Disposal <br /> Distance to nearest: WON Foundation Property Lina�....,. <br /> LEACHING UNE M No. i Lerpth of lines Total length/elks <br /> FILTER BED 0 Distance to merest: WOO,..�.�. Foundation. Peopeny Lina <br /> SEEPAGE PITS i I Depth Sin Number <br /> SUMPS . ..__.�LI,Distance to Ramp! Wens Foundailort, Prow"Lirw...r,...�,.... <br /> DISPOSAL PONDS 0 <br /> I hereby cenity that I haw prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws. and <br /> rules and regulaliom of the San Joaquin CouaW► <br /> Home owner or licensed @goat's signame esniltQho followinO:"I cOnily that In the performance of the work for which this permit is Issued. I shed not <br /> employ any person In such manner as tot to workman's c6mponaallon laws at C@liloinla." Contractor's hiring or sub•controcling signatuto <br /> canihu the lollowing:N certify that ft v1 the work for which this permit Ie Issued.I shall off0ay parsons subject to wor iniari's compsnaa- <br /> tion laws of Comfwrds N <br /> The applicant swat call for Dep tido,. Complete Browing an reveres nide. See, 1 u V f'tL,r t^, T`Y�1 en l m <br /> SignedTitle: ,J Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or aroat Inspection by Dote Final Inspection by Data.,.....,....�.. <br /> Addillonol COMm tits: <br /> Applicant . Return &U copies tot San Joaquin County Public Health <br /> Services, Eavitrohaental Health POrmilt/Searrices <br /> 1601 X. Haselton Avs., P 0 box 2009. Stockton, CA 45201 <br /> CK I <br /> IEEE AMOUNT DUE AMOUNT REMITTED CASK RECEIVED By DATE PERMIT•NO. <br /> ♦ EM 13-74 IAEV.Us sl <br /> EN t�•>w <br />