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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t ' <br /> Application is hereby tade.to San Joaquin County for a permit to construct and/or lnstall the work herein described. This <br /> application is ewde in carepllance with San Joaquin County Ordinance No. 549 and 1862 rued the Rules and Regulations of San <br /> Joaquin County +Public Health Be ices. �/�7�// �j C <br /> Job Address �� q/, /v_Z A�-"- •� � City <br /> /"/�"�- -Y Lot Size/Acreage V, ` <br /> Ownais Name .��6�lv y � Addres � Phone <br /> q/r Zeff VF2 <br /> �4 Contractor " ddress [X�07(/ //[/�.L[.f�`� License'No. Phone <br /> TYPE OF WELL/PUMP s NE WELL J' WELL REPLACEMENT r . DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR [IOTHER ❑ Monitoring Vpll C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK ¢SEWER LINES DISPOSAL FLO. PROP. LINE 1! <br /> FOUNDATION .4-�J/ AGRICULTURE WELL ^ OTHER WELL � PITS/SUMPS LS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS K <br /> ❑ Industrial ❑ Open Bottom Manteca Dia- of Well Esuvation Dia. of Well Casing <br /> �T AI,whilic/Private Gravel Peck ❑ Tracy Type or Casing_ Ak�e Specifications _ <br /> I Public r 1,1 0?at i r1 Delta Depth of Grout Seal ��_ Type of Grout <br /> I i I...Ustion Approx. Depth I I Eastern Su if SsnI Installed by <br /> ' �_ <br /> Repair Wort Done v Type of Pump � f'� H.P. � State Work Dona - <br /> Well Destruction ❑ Well Diameter Beallttg Material i Depth <br /> Depth - Filler Material i Depth I i <br /> TYPE OF SEPTIC WORK, NEW INSTALLATION I 1 REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted it public sawer is <br /> aveBable within 200 feet.) <br /> -Installation w81 serve: Residents — Commercial— Other 4 -� <br /> Number of living units: Number of bedrooms <br /> - Character of aotl to a depth of]fast: �~ Water table depth <br /> SEPTIC TANK ❑ T t <br /> yPa/Mfg Capeciip 1 No. Compar(mann <br /> PKG.'TREATMENT PLT.❑ r I r Method of Disposal <br /> Dlatance to nearest: Well Foundation Property-Line <br /> LEACHING LINE _❑ No. 8 Length of lines ;Total length/size <br /> FILTER BED ❑ Distance to tssarest: Well Foundation I Property Line <br /> • n,t t <br /> SEEPAGE PITS T\ 1 I Depth `/ Size .Number' <br /> SUMPS _ ll Distance to-rwreair`-';Well -`�Foundetion " Property Lina �? <br /> DISPOSAL PONDS•_ _❑_ .�,. .. _ II VT <br /> I hereby certify that I have prepared this application and.thet the wo4k.will be done in occ6rdance,with-San Joaquin county ordinances. stattilows, and <br /> rules and regulations of the San Joaquin County \ " <br /> Home owner or licensed agent's signature csrtifAs the to "I unity that in the performance of the work for which this permit is tissued, 1 ehalbnot <br /> manner any Parson in such anner ea to become amblect to workman's compensation Isws of California." Contractor's hiring or subcontracting spneture~ <br /> Unifies the following: '1 certify that in the performance of LAa'woik for which this permit it isivari'tshall employ persons subject to workman's compensa <br /> tion awn of California." A I '`- 9 <br /> The applicant'//%�I Ulf . Complete drawing on reverse Ido._ I <br /> Signed x :ua_ bets: <br /> _- <br /> F R DEPARTMENT USE O LY T <br /> Application Accepted by f= (CA - Date S7 Lo __S - Area <br /> w-[S Final Inspectionb <br /> i Ph or�Inapacdon by� _. ate _ _y �� �^ <br /> Addlbonal Comment:i <br /> Applicant - Beturn all copies to: Baa Joaquin County public Health Services <br /> t' Environmental Bealt h'peroit/Services+ <br /> `.445 N San JOsqulm, p O Box'2009, Btkn, CA 95201 <br /> ' FEE I AMOUNT DUE AMOUNT REMITTED I CASH I RECEIVED BY DATE PERMIT NO. <br /> P <br /> t} -13y ° <br /> q rFM N'IREv.n.na1 ' I <br />