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fi APPLICATION FOR PERMIT <br /> 1� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRON103NTALI HEALTH DIVISION Copy445 N SAN JOAQUIN; PHONE (209)468-3420 <br /> P O BOX 2009, STOdKTON, CA 95201 <br /> PEMT MIRBS I XEAA EROM DTISSUED <br /> (Complete in Triplicate) <br /> Apylieation is hereby mads to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> spglication is made in cotoliance with £Ian Joaquin County Ordinance Ifo. 1662 and the Rules and Regulations of Sari <br /> Joaquin County Public Health Sery 11 <br /> JOb Address Qs sM0406© z City t Size/Acreage +! <br /> 7s Co . hone .Ltf --443' 13 <br /> Ownar�Nam rasa <br /> CflntiraCt �tAdtlres3 e` l'"Ffr� _ License NAMM Phone vv r <br /> TYPE .F WELL/.PUMP:___ , .NEW WELL'C3 , . WELL REPLACEMENT n DESTRUCTION t of Service Well Ll- - - PUMA INSTALLATION ❑ SYSTEM REPAIR ❑W f OTHER ❑ `1Monitoring Well C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LIME <br /> --i-- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .T ! <br /> INTENDED-USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 Industrial ,w O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing (� <br /> n oonwetic/Prwate ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications `�1 <br /> I.1 P%rblie n Other fl Delta Depth of Grout Seat Type of Grout <br /> I I iriligation —.Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump H.R. - _ Stats Wo D 1 <br /> Wed,Deir'truction. VZI Diametai f ing`Y-i erisl Jti Depth - L J e <br /> Depth 11er,Dtaturisl di Depth 0 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIOhI (J� DESTRUCTION I I,.{No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Initalletion will serve: R _ Commercial_ Other <br /> Number of liviit units: mber of bedrooms <br /> Character of soil to a depth of 3 fee �� Water tatrl ,depth Q <br /> SEPT16 TANK. ❑ Type/Mfg CapacityNo. Compartments <br /> PKG:--TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest. Well Foundation Property Line <br /> LEACHING LINE_, C1 No. 6 Length of linea Total length/size <br /> FILTER 6ED Q Distance to nearest: Wad Foundation property Line <br /> SEEPAdE PITS I I Depth Si <br /> } ze "� Number <br /> SUMPS' . L1 Distance to t: Well `undation Property Lire <br /> DISPOSAL PONDS ❑ <br /> I hereby.conify.that I have prepared ttri application end that the work will be don in accordance with San Joaquin county ordinances, state lours, and <br /> rules anif regulations of the San Joaquin County <br /> Home owner or. ' nae fit's signature certifies the following: "1 csrtity that in the performance of the work for Which this permit Is issued,t strati not <br /> arty k any rsori in such nor as to become eu to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifiq the albwirrQ:"1 cert that in Orin t the work for which this permit is issued,i shall employ persons subject to workman's cornpenss- <br /> tion laws tallfor ^°— <br /> The an, <br /> mu c ad'r ire to drawing on ids. ��,/ <br /> Signed ��`title: _ `�""" �� Data. <br /> Rt - r <br /> " (1 � --FOR DEPAiiTMENT USE ONLY i <br /> Applicatlon Accepted by Date Area { KIA , <br /> r <br /> Ph or Grout In p coon by Date C Final Inspection by JD_ate <br /> Additional Comments. <br /> _: 17,, t(ttl�T•�If`"_l�. .or—,1,1'� s(A. O'f ��l�fa.�-_ITiF aF L���Tf7lk�afrr_�Tluc�j, <br /> r - - -- - <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Saviroumental Health Permit/Services <br /> 445 N.San Joaquin, P 0 Sox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PEAma'NO. <br /> INFO / CASH <br /> . off Ias�laEw,r.ear � ��°DC7 bar ®Q �,� l y .3Q5S 7 . <br />