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FEH 15 195 04 04PM FUDR` WEST ROSEV,�LrLICATION P'22 <br /> SAN JOAQUIN COMITY PMLIC HEALTH SERVICES <br /> ENVIRONZOTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O HOZ 2009, STOCKTON, CA 95201 <br /> P73RYIT E%PIRTS 1 YEAR E= DATE ISSIIED <br /> (Complete in Triplicate) <br /> Application 1e hereby Made to Sas Joaquin County for a permit t0 construct and/or Sna Loll the work hereln described. This <br /> opplltatibn is ride in eeapUanee frith San Joaquin County ordinance No. 549 and 1562 and the Rules sad Reguletlens of San <br /> Joaquin County Public Health Services. <br /> Joh Address Cay h1''blA Lot Size/Acreage <br /> Owners Nam. 5 �/ O�/. / Address �V 40' , t T.)p C-11 `1'"�'J Phone <br /> Contractor � r•r•` !-.l/r; re Address '%r°'' PFJ-" i�. I %'��-Y/..to : License No., <br /> i <br /> TYPE OF WELL/ MP! NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTION A Out of Service Well ❑ <br /> ?UMP INSTALLATION C SYSTEM REPAIR C OTHER C llonttoring Well C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE �— <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industry, ❑ Own Bottom ❑ Manteca Die, of well Excavation Dia. of W"Cooing <br /> M Domntic/Private ❑ G'w4i Pack ❑ Tracy Type Of Cas.ng_ Specificabons <br /> I'I Public: fl Other 1-1 Delta Damn of Grout Seal Type of Grout_ <br /> I I Ifngalron _Approx. Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done ❑ Type of Pump 4.P. Starif Work Qne <br /> Well Detruction 'X Well Diynslsr SaLling Material i Depth tj I. ' AA w i <br /> Depth Piller Material A Depth L71rI. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I (No scout ayslern 08r fled if public sewer is <br /> available within 200 IeeGl <br /> installation line anew: Rasgenea_ Commerelel_ Cmer i <br /> Nuff0m Of Wing units: - Number of bedrooms <br /> Character of soil to a depth of 3 fen: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Cs"cliv No. Companmante <br /> PKG. TREATMENT PLT. C Method of DispWN <br /> Disband to rNarak Well Foundation Property Lute <br /> LEACHING LINE Cl No. b Length of lines Total Ianm t <br /> I <br /> FILTER BED 'D Distance to nearest: Well Fovncla ion Property Line <br /> SEEPAGE PITS 11 Depth Size Nwrri I <br /> SUMPS LI Distance to nearer: WAS Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I nenpy certrty,that I have prepared this application and that the work will be Cone Irl accordance with San JoaOuin county ofdlltMds, State Imes, and <br /> /ulna and regiMtiOM Of the San Joaquin county <br /> Harts owner or licensed agent's srgneturs certifies the following: "1 Certify That In the Peliom once of the work for which trim perrM is issued, 1 shall not <br /> 4 any Parson in such monner as to becerhat supfsn to worarnii comDansanDn laws of California." Contractor's Miring Of willcontreQmg signature <br /> anifies the following: "1 certify trtn M tna perfomynte of the work for which this permit Is issued,I shall employ Parsons subject to workman's compane- <br /> rion laws of Calikvnio." <br /> The applili \mf\\\,uraa,,tea fot�`P�1 r Insoections COrrtpine drawing on ri ase side. <br /> Signed Title: Oro: <br /> i r FOR DEPART M'IE OT USE ONLY <br /> Appliraleen Accepted by - ._ _, Date AIE� r L / Are <br /> Frit er Grour Inspection by OAS Final Inspection by Oate <br /> Additional Carttment■: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services, <br /> Eoviroomental wealtn Permit/Servicer, <br /> 445 N San Joaquin, P O seri 2009, Start, CA OS201 <br /> FEE INFO AMOUNT DUE AMOUNT REatITTim CASH RECEIVED aY DAVE ►ERarr"rso, <br /> . 11M IaaV.,iwa, . .—. . IX l — /�,O �� I �pn,��, .� .�S 5 Payee 73A <br /> .r4at tL�' IIISSSii, `� (r <br />