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.�- to <br /> APPLICATION <br /> SAN .JOAQUIN COUNTY PUBLIC HEALTH SERVIC33' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> � • ,,.• e <br /> •145 N SAN JOAQUIN, PHONE (209)468-3420 S •r,41 <br /> P O BOR 2009, STOCKTON, CA 95201 UC� Z la Ir- <br /> PE IM1TER FS 1 YEAR FRQM! DATE ISSUID <br /> (complete in Triplicate) <br /> Application 1s hereby ride to San Joa,uln County for a Permit to construct and/or install the work herein described. This <br /> applicatloa is amde i•r comilipl'ance with San Joaquln Courcy Ordinance No. 5+9 and 1E1b2 and the Rules and ReSul"lons of San <br /> Joaquin County iLblic Health Sgrvlc►s. <br /> 7,7 <br /> Job Address t!" ,)'S C•tv Looms Loa SlaelAcrearte _ <br /> Poona -36 <br /> Owr's A,l,lress f a. <br /> ne <br /> . LL'fLSclx� A,1r1,•%t . 1p (.�_.lir tJJ �C e'+tt No�•�/����_.Phan! <br /> .onnac;a — <br /> TYPF OF WELL PUMP NEW WELL WELL nEPLACEMEN DESTRUCTION �l put of Se11 Well LI <br /> PUMP INSTALLATION ' SYSTEM REPAIR OTHER C <br /> Monitorin{ W%" f. <br /> SEWER LINES DISPCSAL FILO PROP LINE <br /> DISTANCE TO NEAREST SEPTIC TANK — -- ►ITS/SUMPS —_ <br /> FOUNDATION AGRICULTURE WELL OTHER Will <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUfTION SPECIFICATIONS <br /> Dia of Wee Casing <br /> (1 Inrvsinel U Open Bottom Manteca Ora of We"Esuvatron� Speaftcattons <br /> � miv <br /> oashe/Prate Ll Gravel Park Tracy Type of Casing <br /> I'I PtdNrc <br /> I 1 Omer i I Delta Depth of Grout Seal Type of Grout <br /> I I farpatron ___ APlro■ Depth Esstam Suitt Soul Installed by__ <br /> c H P. _ State Work DOM <br /> Repan Wort Dont U Type o1 Pump .y `l.�t-- Msll;; Material E Depth <br /> well Destruction O Wen Diameter s <br /> Dept,_ Filler Material i Depth - <br /> TYPE Of SEPTIC WORK. NEW INSTALLATION 1 1 REPAIR'AGDITIUN i ' DESTRUCTION I I evadable vrsystairri 200leetlled rt PWrbk MvNr Is <br /> itoInstallation will serve Residence_ COrnmerCiaf_- Other <br /> Number of hiring units __ Number of bedrooms — (/ <br /> Water table depth <br /> Character of e)A to a depth of 3 tees <br /> SEPTIC TANK C Type/A'fg Cspaeity No.ComWrtmar+ts <br /> PKG. TREATMENT PLT.Ll Method of Disposal <br /> Distance to nearest well_ Foundation Property Line <br /> LEACHING LINE l! No. 8 Length of fines Total lengthfail• <br /> FILTER BED LI Distance to nearest. Well Foundation Property line <br /> Number <br /> SEEPAGE PITS 11 Depth __.___—Si7e -` <br /> SUMPS I! Distance to nearest well_—__ Foundation— --- Property Line <br /> t <br /> DISPOSAL PONOS 1-1 <br /> i hereby rerUfy that I have prepared this sppl�c•bon and trial the work will W AVnd m actor lance with$•n Joagwln CWnly OrtlrMnCef. alata lawf, and <br /> rules and regulations Of the San Joaouin County <br /> Home owner or licensed agents signature certlhes the f0aowinp. 'I Candy that in thio parfon�•ncs of the work too wMch this perrtwt is-saved.I shall not <br /> employ any person m such manner st to become subject to workman's compensat,on laws of California" <br /> Contractor's hiring or wbconttactinq spneture <br /> certifies the f ng:'"I comfy that.n the porlormaires of the work for which this permit a awed.I atoll employ persons subject to workman's cornpenM <br /> tion 11 or is'• <br /> The ap ce must call for all r ,ad(naps .r ns Complete drawing 4,* *,Tfmli /�Signed — Tills. . Date:FOR DEPASE ONLY <br /> Application Accepted by --- - <br /> Data <br /> Pit of Grout Inspection by ----- <br /> Data Final Irlsoili y Date <br /> Additional Comments: ._ <br /> APPllrnnt - Hntnrn all inDlerr tr. I��virimmentalc H ea lthit Permiblir Lt/Servicenvlcen <br /> 415 N San .ioaquln. P o jinx 2009, Stkn, CA 95201 <br /> FEE AMOUNT RFMITTEO x RECEIVED By OAT[ HERMIT NO. <br /> AMOUNT OUE CASH <br /> L�t/wer - A +1 <br /> IM Ir 38 _.L <br />