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APPLICATION FOR PfAhV0AQmC0tqM.pU$UCHpALTH 5� : <br /> SAN JOAQU IN COUNTY LIC HEALTH N] AL HEALTH DMSIION <br /> ' =RONMENTALEALTHOAQUIN PHONE (209)493 " PERMIT �d <br /> �IUT <br /> 311 MW& � 2009, STOG$TON, CA 95201 <br /> MAIM as <br /> w � 1 Y FRNDTE S a <br /> (Complete Pff Triplicate) <br /> Application is hereby made to Saa}}Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cccipliancetvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services r J. <br /> Job Address City 4- Lot Size/Acreage <br /> 1 <br /> x <br /> Owner's Name Address Phone <br /> qA I V/ <br /> Contractor ddress • nse Nr Piton + / <br /> TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT D DESTRUCTION 0 out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE , <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA°.-CONSTRUCTION SPECIFICATIONS. - <br /> I; 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia: of Well Casing <br /> CI Domestic/Private ❑ Gravel Pack Al ❑ Tracy Type of Casing_ Spicifications <br /> 1'I Public 1-1 Other F1 Dela 4 Depth of Grout Seal Ty4e of Grout� <br /> a r. <br /> I i Irrigation —.Approx. Depth I I Eastern 1 Surface Seal Installed by <br /> Repair Work Done U Type of Pump, ? H.P. State Work Done -1 <br /> Well Destruction O Wall Diameter Sealing Material i.Depth <br /> Depth <br /> t Filler Material i h <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION V11No septic stem if <br /> P Y Peretitled public sower is <br /> .available within 200 feet.l <br /> rve <br /> Installation will se : Residence!i Commercial— Other SY <br /> Number of living units: _ _ <br /> Number of bedrooms _ <br /> Charectir-o(NoG to a depth of 3 feet: } `/ Water tableld pth ! 1 <br /> r <br /> SEPTIC�NK. 0 Type/Mfg 4 Capacity zSk Na. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to..nearest: i Well Foundation Property Line <br /> j . <br /> LEACHING LINE ❑ No. a Length of lines i Q X l length/size C sU <br /> FILTER D Distance too f Well Foundation ,d Property Lined , <br /> SEEPAGE PITS I $ �+rasi3�-a Al.MAM-DWSION Number <br /> SUMPS L1 s <br /> �'°�� Foundation Property Line <br /> DISPOSAL PONDS ❑ W r i <br /> I hereby.. fy that I have prepared this application and that the work will be done in accor with San Joaquin county ordinances, stats laws, and <br /> rules an&Mations of the San Joaquin County i ��� <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the peAorriiti .o of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hit ing or sub-contracting signature <br /> certifies the fo#owing: ''I Certify that in the'performance of the work for which this permit is issued, I shall employ persons subject to workman's companse- <br /> tion laws of California." t <br /> The applicant rnust call f r all raguir inspections. Comp a drawing on reverse side. <br /> Signed Title: Date: r✓ <br /> FOR DEPARTMENT USE ONLY <br /> 9 <br /> Application Accepted by _ _ gyp.. Datreait 11 <br /> Ph or Grout Inspection by Date Fins] Impaction b Date �® <br /> Additional Comments: + rf� ,�Nwr <br /> Applicant - Return all copies to: San Laquin County Public Health jrvice0 <br /> { Environmental Health Permit/Services <br /> 1 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE <br /> INFO AMOUNT DUE 0 AMOU` REMITTED (LLK I A RECEIVED BY DATE PERMi7'N <br /> a Eli 13.26 IIIEV.1/M 61r , Z) <br /> EH 11.3e <br />