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... APPLICATION FOR PERMIT SR# <br /> SAN JOAQUIN COUNTY PUBLIC HEAL'I'R SER IA#®# <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOC%TON, CA 95201 FAC# <br /> (209) 468-3447 <br /> R V# <br /> (COfnplete in Triplicate) <br /> Application is hereby made to Sao Joaquin County for a permit to construct and/or install the work herein described. This <br /> application Is made in c0e�liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address �J_Z7 /��4PiPo5A )� CiVS ZF'(-,V -7 J Lot Sise/Acreage /,SA <br /> Owner's Name OSLO,/ COA A✓i5Ff !v r• Address 2313,i1A P/Pi 2D S'T7Y v"n j Phone <br /> Contractor Address /06,76h & <br /> i• m ,4ul� � d4. LZLdc <br /> 9- 70 License No.4,11,786, Phone(L <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ OESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR C) OTHER (9 Monitoring Well LT <br /> DISTANCE TO NEAREST: SEPTIC TANK /CO SEWER LINES V/,a '' DISPOSAL FLD. P-C) ' PROP. LINE <br /> FOUNDATION 7171 AGRICULTURE WELL dV/A OTHER WELL -O' PITS/SUMPS -4/lA <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial O Open Bottom 0 Manteca Ole. of Well Ekcavation '1 Dia. of Well Casing !L)On-a- <br /> U DOmesile/Private 0 Gravel Pack O Tracy Type of Casino- A11A Specifications NiA t'Lv4 <br /> M Public I.1 OtherC <br /> O Datta Depth or Grow Seal 21 12HCEA f� r <br /> Type of Grout C4( v" <br /> ❑ Ifouaoon Approx. Depth ($.Eastern Surface Saul Installed by CZI 'TTZAGTOIZ- <br /> Repair Work Done U Type of Pump <br /> H.P. Slate Work Oona _ <br /> Wall Destruction 0 Well Diameter Sealing Material a Depth UJ <br /> Depth Piller Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/AD0I TION L1 DESTRUCTION CI (No septic system permitted it public sewer is <br /> Instillation will serve: Residence _ Commercial <br /> available within 200 feel.) <br /> _ Other <br /> Number of living units: _- Number of bedrooms <br /> Character of soil to a depth of 3 bet: <br /> Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity_ No. Compartments \ <br /> PKG. TREATMENT PLT.CI <br /> ty <br /> Line of Disposal <br /> Distance to nearest: Well Foundation Property tho <br /> LEACHING LINE Ll No. 6 Length of lines <br /> FILTER BED Total length/346 <br /> Distance to nearest: Well Foundation __ <br /> __ Property Lina <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest. Well Foundation <br /> DISPOSAL PONDS <br /> 0 Property Line \ <br /> I hereby conity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and <br /> rule and regulations of the Son Joaquin County 444 qqq <br /> Home own$(or licensed agent's signature cenifies the following; "I cenify that in the performance of the work for which this permit is issued, I shall nor 'A}\ <br /> employ any person in such manner es to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signatw° <br /> cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ <br /> tion laws Of.Colifomis - p Y persons subject to workman's compensa <br /> The eppllcan gymuAt) c or all r quired Inspections. Complete drawing/ofn�reverse side. <br /> Signed ![/ Title: 66 15L'14 <br /> Date: C// <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by LETED <br /> Date C Z�7 `r " <br /> Pit or Grout Inspection byt� ��! /� ��77 Date Final Inspection by <br /> 244��aE�i Area <br /> Additional Comments: --a9J A-�� /Ay'�G� •3-sy �p •rj-Z)` �� 1 <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 <br /> aE! 9y <br /> UNT DUE AMOUNT REMITTED --3601 <br /> CASH RECEIVED BY DATE PERM11 NO. <br /> /J J <br /> o g <br />