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APPLICATION FOR P& LTCC---`"—...----'— <br /> SAN JOAQUIN COUNTY PUBLIC T&SREECf/Ie-9- L <br /> ENVIRONMENTAL HEALTH DI Iyi tI"�vfiG;,,: <br /> 445 N SAN JOAQUIN, PHONE (2 #� <br /> P O BOX 2009, STOCKTON, Cf pWC Q(]!1 <br /> PERK T IRE FR FM � pH <br /> (Complete in Triplica '3T— <br /> AN14"stion i• hereby leads to San Joaquin County for a Permit to construct and/or install the vert hereto described. This <br /> application is imade in compliance with Sen Joaquin County Ordinance No. 549 and 1662 and the Rules and Ra/ulatione of San <br /> Joaquin County Public Health Services. <br /> Job Address .. az ICityQ _ Lot 81 se/Acreage <br /> Owner's Name IyL Address ` Phone <br /> 1 <br /> Conlnacla��ILI I IgAS tldreis /r <br /> License No. _1i/"Phone_ <br /> TYPE OF WELUPUMP. NEW WELL ❑ WELL REPLACEMENT 01 DESTRUCTION ❑ Out of Service Yell <br /> PUMP INSTAI.LATION O SYSTEM REPAIR ETHER ❑ Monitoring Mall I7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. .PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL==,*. PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA.TIONS <br /> Cl Industrial ❑ Open Bottom U Mantaca Dia. of WON Excavation 'Die. of Well Gating <br /> Cl Oomsaicr Priwu ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Pubae C7 Other fT Delta Depth of Grout Seal Type of Grote <br /> I I tnigatron _Approx. Dept 1.1 fatten, Surface Seal Insured by <br /> Repair Work Done L] Type of Pump M.P. State Work Done �] <br /> Well(Destruction O WON Diameter 8ea1LnS ,epth <br /> -- Depth /l 7 �— Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION—JI DESTRUCTION I I (No seplic system permitted it pudic sewef is <br /> available within 20D feet.) <br /> Imuastwn will MM: Residing _ Commercial_ Other,__ <br /> Number of liwng units: _ Number of bedrooms <br /> Character of sole to a depth of 3 fen: _• Water table depth <br /> SEPTIC TANK Ll Type/Mfg Capacity No. Co, psmmnta <br /> PKG. TREATMENT PLT.LT i Mnhod of Disposal �I <br /> Datancs to nearest: Well_ Foyndation_ Property Line N <br /> LEACHING UNE 6 No. g Length of lines _ ---J Total length/size <br /> FILTER BED O Distance to mareal. Well i Foundation _ Property Liar <br /> SEEPAGE PITS I I Depth _Sire Number y <br /> SUMPS _ LI Distance u rwrast: WWI Foundation Property Line <br /> DISPOSAL PONDS O - - <br /> I hereby earthy that 1 Mw prepared this APpllcnion and that the work will be done n accordance with San Joaquin county ordinances, state laws, a2d <br /> rotas aha repuutiaM of the San Joaquin County <br /> Home owner a licensed egsnt's epnswre codifies the following; "I codify (het in the performance of the work for which this permit is issued, 1 shelf rql /� 1 <br /> employ env par such monster as to become subject to workman's compensation Iowa of California.' Contractor's hiring or sub-contracting signature 1pllf/ <br /> cent I" the : "I certify thrs in the panfmrrisme of the work for which this permit is issued, 1 shall employ parsons subject to workman's wrrlperlw <br /> tion Tawe CW' r1 <br /> The applies I eta for all rant inspection . Complete drawing on r r e de. <br /> Signed �� Title: <br /> Data: <br /> QFOR DEPARTMEN BE ONLY <br /> Application Accepted by _�^ 1–.{,�yL� — Dau <br /> Pit or Grout Inapction by Data Final Impaction by Dna / -2 93 <br /> Addhioml Commence: ' <br /> Apritcant - Return all copies to: San Joaquin County Public Health Services <br /> Sovlronmental Health Permit/Services <br /> 445 N San Joaquin, p O Box 2009, Stan, CA 95 01 S V ei R (T <br /> IP�IfJ FEE AMOUNT DUE AMOUNT REMITTED �'\ <br /> INFdO ,,qq��� CASH RECEIVED BY DA PERMIT NO. <br /> 6�3 3 v 19 93 -7! <br /> i <br />