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t91 <br /> APPLICATION FOR PS p��y� `3 ' <br /> SAN JOAQUIN COIINTy PII ZOCR T.6"'VT s_L/)z /D <br /> ENVIRONI[ENTAL HEALTH 1 1* Y� y <br /> 445 N SAN JOAQUIN, PHONE i 9MdBB 3 7S <br /> P O BOX 2009, STOCKTON, 7A <br /> Mt PERMIT IR S FR f <br /> (Complete iD Triplic t <br /> Application is hereby mode to Bea Joaquin County for a permit to construct end/or snots e <br /> apPlicatlon Sa made In Corpliance With Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servicoe. <br /> Job Address /?n sc-Goa' Ae.U.CrA Nd /+cay4-(��1900e4017.0111,tsl�I.-.�//�Lot Blse/Acreage <br /> Owners Name <br /> e J'e z(J!` 14 Address �yid/ .0i BP/hone <br /> Contractor*z,QLtj -1/-aw 6a <br /> Address urz L License No. <br /> 'nor 7V-&e b-y Phone <br /> TYPE OF� NEW WELL ❑ WELL REPLACEMENT Cl OESTRIJCT10N ❑ Out of Bervice Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 /> Cl Industrial O Open Bottom 1.7 Manteca Die. of Well Excavation_ Dia. of Wall Casing -9 <br /> n Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications— <br /> I'I <br /> pecificationsI'I Public fl Other fl Dei Depth of Grout Seal Type of Grout <br /> I I Inigation _Approa. Depth I I Eastern Surface Seat Insta!ad by <br /> Repair Work Dona U Type of Pump H P. Stale Work Dona_ <br /> WON Destruction ❑ Wall Diameter Sealing Hai Z Depth <br /> Depth Piller Material ► Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted it p.Iblit sewer u f l <br /> avaitabte within ZOO fast.! !} <br /> Installation vrill serve: ReOidanco' Commercial_ Other <br /> Number of living ulvi _/ Number o/bedroom , <br /> Chw*Ctw of WN to a depth of 3 foal: _At;)II/10/e Water tsbla depth <br /> SEPTIC TANK ❑ Type/Mfg - CsPeciiy No. Compartments <br /> Pli TREATMENT PLT. ❑ Method of Disposal [%3�3 <br /> Distance to Mares[: Well _ Foundation _ Property Lula _'1 <br /> LEACHING LINE RI No. 8 Length of lines ' �+ <br /> Total Iength/size ��rs . 0 <br /> FILTER BED ❑ Diatsnu to ManiWent _ Foundation Ur _ Property Line_J y <br /> SEEPAGE PITS jor Depth Aft _Size_ <br /> Number <br /> SUMPS LI Diatance to Mai Wall Foundation Proxrty, Lim <br /> DISPOSAL PONOS ❑ r <br /> 1 heMby unify,that I have PreparW this application and that the work will be done in accordance with San Joaquin county ordinances. state bwa. and <br /> rules and regulations of the San Joaquin County <br /> Home owner Or keened agoni tigM,MrO conifiaa the following: "I Certify that in the performance o1 the work for which this permit in laoued.1 soli nor <br /> employ any person in such mesmar e's to bacomo ilubjacl to workmen's compensation laws of California." Contrli hiring or sub-contracting signature <br /> unifies the following: '9 corfity thai in the padornynCa of the work for which this permit is sound,I shall employ peri subject to workman's compeit". <br /> tion laws o1 Cslilonis." <br /> The appliscant for an <br /> regrequuwadinspections. Complete drawing on reverse aide. <br /> Signed 7(-ii \ 'G" '!�'�" Title: Data: _4-i.9—9✓ <br /> q/ FOR DEPARTMENT USE ONLY <br /> Application AccopvA W ��� `—N5 <br /> _ Date � � sAran <br /> Ph o Grout Iw,xsctlon by Daae Final Inspection by- 1, ,a4 Daae---/ <br /> Additional Comments: 04 - 4 'If °t'LI (LL f Si0( - �F <br /> _' <br /> App+Scant - Return all cople.( to: San Joaquin County Public Health Services <br /> EavirOlur tel Health Persit/Hery lcea 1 <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 201 <br /> IE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH rrR ECEIWED By PERMIT NO. <br /> Ali 11.51511 9.3 <br /> 1N 1411 <br />