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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY-PUBLIC ELEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOA 20090 9TOCKTON, CA 95201 <br /> (209) 468-3447 Q <br /> PERMIT SXPIRBB 1 YEAB PROM DATESI SURD <br /> (Complete. in Triplickte) � <br /> Application to hireby mada,to Baa Joaquin County for a permit to construct and/or install the work herein described. This <br /> applicatioe is nude in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquill County PublicHealthSer/vices. _AP14 Gm?*. 0S_b- le <br /> Job Addriai AJf � /�M,QSr7.4iLJ � Q�r/!JE Clty fMk-]VIU Lot Size/Acreage lA e- <br /> ,Owner's Name '_lrLr'RA/T/4f= LaJG Address 3449 14pa--ttterrl Pie S4CEA44_enrFO Phone _-fez- Z9Z <br /> Conlraelo F Addresto dd � 4l G7� PhoneS�7: 7 <br /> �p�,��7� __ License No. <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 out or Service hell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SA SEWER LINES Z-42-6 DISPOSAL FLD,NI,�__ PROP, LINE 3' _ <br /> FOUNDATION 2 AGRICULTURE WELL &,0 OTHER WELL.192-L— PITS/SUMPS A[ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industfisl ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2 ^ <br /> 0 Domeslic/Privsla 180 Gravel Pack ❑ Tracy Tylie of Citing 21/4' Specificatlons e d <br /> C] Public 1:1 Other 000116 Depth of Grout Seal $veFACE Type of Grout CaoNC2dC72F <br /> CJ Inivalion y..TL Approx. Depth © Eastern Surlici Soul Initollad by rf7F!-tl2�cTo <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Wall Destruction O Will Diameter .Sealing fliterial i Drpth <br /> Depth rilloiMaterial i Depth <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATION❑ REPAIWAODiT10N L7 DESTRUCTION Cl INo septic system pvrnillod it public sews( is <br /> available within 200 lest.) <br /> Installation_will sirvs Rssidence-.-,__Commorclel=Other- � <br /> fJumber of Ilyinq units: - Y Number pf bjdraorns - - - i <br /> Charoeler of loll to a depth of 3 fast: Water table depth <br /> SEPTIC TANK. El Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT,0 <br /> Method of Disposal <br /> Distance to nearest: Well Foundition Property Lino <br /> 3 <br /> LEACHING LINE Cl No. b Length of lines Total length/size <br /> FILTER EIED 0) Distance to nearest: Well Foundation P(openy Line <br /> SEEPAGE PITS 11 Depth 9izi Number <br /> SUMPS L1 Distinct to nearest: Well Foundation Propeny Line <br /> DISPOSAL PONDS ❑ <br /> I hereby esnlly that 1 have prepared thio appkatiorl and Thal the work will be done in eccwdance with San Joaquin county ordinances, state ta <br /> rules and regulations 61 the Son Joequln County ws, and <br /> Home owner or licensed igint's signature certifies the following: "I cenily.that In the performance of the work for which this permit Is issued, I shell not <br /> @-Ploy any patron In such manner as Io become subject to workmen's compenialion taws of California." Conlrictor's hiring or sub•contrecfing signature <br /> cirtillea the followings "I Canily that In the performance of ohs work for which this permit Is issued, I shall employ parsons subject to workmen's compensa- <br /> lion taws of Californls." <br /> The applican m I Cal r all roQuued Inspeclions, Complete drawing on reverse s de. <br /> Signed Title: Dote: <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Enopectlon by <br /> 5 Date Final Inspection by Date <br /> Additional Comments: <br /> i <br /> Applicant - Return all copies tot BAN JOAQuIH COUNTY PUBLIC,HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION P8RM1T/SERVICES <br /> 445 N SAN:JOAQUIX. P O,hOX 7009, STOCKTON. CA 95201 <br /> FfI AMOUNT DUE AMOUNT Alimi TEO <br /> INFO CASH RECVvEo ay OATS PERMIT'NO. <br /> ;r+ 1),)1 tal:y.r/sat <br /> EH:/•b <br /> i <br />