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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRON KEN TAL HEALTH DIVISION <br /> P 0 BOX 2009, STOMTON, CA 95201 <br /> (209) 468-3447 <br /> EMIT RMPIRES 1 Y AR pR.OY DATE ISSLIRD <br /> (Complete is Triplicate) <br /> Application i• hereby smadtfto Baa Joaquin County for a perm c to construct And/or install the work herein described. This <br /> apylieatloo to Cade in compliance with flea Joaquin County Crdir.sncs Ko. 549 and 1B6Z and the Rules and hs Lttone or ban <br /> Joaqula catua y Public Nealth services. �' <br /> Job Address 02 J —&-41/L'F le t-f1 city S 70LR 7orv_ Lot Blis/Acreage <br /> Owrsera Name ar's'?'n 1L Gu AJ&sss __ I;2 J U 4 e A? Phons .`)-A -'; <br /> Contracfa S'Fat �G t[t !►bj/Ftt( Address 2G13 A JFar Mo,ErnLlcen•s No. c_ -r, <br /> Hhune <br /> TYPE OF WELL/PUMP NEW WELL 'J WELL REPLACEMENT CESTRUC*ION G Dut —well O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ lionitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK �- SEWER LINES /D r,' _ DISPOSAL FLO.____ PROP LINE (5 0 <br /> —_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ?[In"nal O Open Bottom O Manteca On. of WON Excavation A Dra. of Well Las,nU <br /> U Oomostie/►nvaq O Gravel Pack D Tracy Type of Casing_ ?PC Specdlcalluns \ <br /> C3 Public aO—.tw ¢i Dolts Depth of Grout Seal _0 .elk•rA[♦ <br /> Trio of Grout C/^^, <br /> d If$Notion x Approa. Depth O Eastern Swrfica Soot Installed by n E lk C, F S f,r<s:A. <br /> Repa.r Work Oona U Type of PWnp t 4 K H.P. State Work Dons_ <br /> WON OeW1Ktlon O Wen Owneter K/•• Bristling Material • Depth_- Al ' <br /> Oeoth 3s;' filler Notarial ft Depth <br /> TYPE OF SEPTI WORK: NEW INSTALLATION REPAIR/ADDITION D DES'.IUCTION G (No MPuc system poirnmao d p,rui, saws$ rs <br /> available wlhin 200 seet.l <br /> IMta4tion wile thaw: Raldeftce,_ Commercw f Other <br /> Number of Yvktg t MS; Number of bedrooms �. <br /> Character of 604 to a depth of 3 feet: _ <br /> _Water table depth T <br /> SEPTIC TANK O Typo/Mfg Cepa,ry No. Companmertis ^1J <br /> ^Kfi.TREATMENT PLT.Ll Method of Disposal _ <br /> Oksianca to nearest: WON Foundation Property If•_ <br /> LEACHING LINE O No.li Length of kers Total length/sirs <br /> FILTER BED n Drattnce to nearest: Well Founds:lon Property Line _- <br /> SEEPAGE PITS I I Depth Sys Number <br /> SUMPS LI O�-t:nca to heerest: WON Foundation _ Property Line _--- <br /> DISPOSAL PONDS 0 <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin county or J.nsnca>., slats laws. and <br /> rulN and regulations of the San Joaquin County <br /> Moms OwMr bf IrcenMd agent's signature cendrss ter following 'I Cendy that in ter porlc✓n•.ancs of the wnrk for*1 Itch In.$Derr,„I n issued. I t',oil not <br /> employ any Person in• th manner as to become subtsct to workmsn'.compensation laws of Caworroa'Contractor's hiring w►,.0­nliacring,jnsture <br /> carul-e.CM followufg enrty WI M the performance of ter work for wnrCh this rrn�$q 4o rod.I shall am lu mons Sub act l0 wcraroan <br /> tion laws of L;aNf�• W D Y t» s compenu <br /> The applicant r, it ale required inspections. Compete drawing!t f- �I -0 <br /> Title: Date: <br /> J� F PARTMENT USE ONIV <br /> Application Atcapted by Dale__ 1 3 3 <br /> Pit a Grout Inspetsron by $ Dols 2'21 F,nd Inspection p <br /> _ Dats <br /> Additional ComrMnts: _ <br /> Applica:.t - Return e•:1 copies So: COUNTY PUBLIC HEALTH SERVICYS <br /> S "1L HEALTH DIVISIL41 PERMIT/SF.NVICES <br /> 44' .OAQUIN, V 0 BUX 2000, bTUCKTUN, CA 100201 <br /> IINFO F--__AMOUNT DUE AMJU141 REMITTEDN 11 NECE��[0 tly _r—_DATE vEHMI n� <br /> CAS., � --� <br /> w i r IAty ,„• O l QCI 2322 �i'1L 7 ', <br />