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lair <br /> APPLICATION_ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE ' ''x9)468-3420 <br /> P O BOX 2009. STOCKT(.a, 'A 95201 <br /> PERMIT EXPIRES 1 YEAR Ftir 'i. ISSUED <br /> (Complete in Trir• f) <br /> /pplieatlon is bereby wade to Sari Joaquin County for a paralt to consti - or instal-' the Work herein described. This ' <br /> application is made is cetlpliance vith Sen Josqul:. County Or1ia►nce so. 4 1862 and th. Rules cad Regulation. of Sar ; <br /> JoKulo County Publ:c Health Set'vlces. <br /> Job Add•ess ���� ` s"��a d�-_..— Cary_ Lot Size/Acreage <br /> reege _ <br /> Cwnar's Name�1111. �$�L_ Address . -vJEIL^��n Phone _ <br /> Contractor��SS f-IS_A 0(css t��]`11 cense Ne. 5 t7 _Phone <br /> TYPE OF WELL/PUM.a NEN.'WELL ❑ WELL REPLACEMENT () DESTRUCTION O Out of Service veil ❑ <br /> PUMP INSTALLr.TION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well Cl <br /> DISTANCE TO NEAREST: SEPTIC TA" SEWER LINES . DISPOSAL FLD. PROP, UNE <br /> FOUNDATION AGRICULTURE WELL _._ OTHER WELL PITS/SUMPS _ <br /> INTENDED U$!; YPE_OF_Wfll _ PRO BL€MAR€A CQty ST RUCTION SOECiFICATIONfS <br /> C Industrial ❑Open Bmtom CI Manteca Du of Wall E.uval on_ Dia. of Well Casing <br /> (I Dorrrst.c/Private 0 Gravel Park 0 Tracy Type of Casing__ Specd.cat.ons <br /> 1"I PubHC 1-1 Otter Cl Delta Depth of Grout Seal Type of Grout <br /> a I I Irrigation _Appro.. Depth t I Eastern Surface Seri Instalkid by <br /> Raper Work Oona U Type of Pump __ -t*. `'„e-Work Dons <br /> was Dastruct-on ❑ WON Diameter - Seallns Hat.er:al i Depth _ <br /> Depth filler tbtarisl Depth <br /> r TYPE OF SEPTIC WORK. NEW INSTALLATION 1 1 R AIR/AOOITION X DESTRUCTION I I (No septic system permtnd J public sewer is <br /> avilao4e within 200 fool.) <br /> Instanstan WIN Soros: Ravdence_ Corrv.4 F.if�-Dimer <br /> N,fftt r of Yvwp urvts: Number of bedrrr xtlt - <br /> Character of soil to a depth of 3 1”"_ 1 Fit l-A _Water table depth ' <br /> SEPTIC TANK 62 TypeJM.g C, Capac.ly /LCIL) No.Compartments ' <br /> PKG.TREATMENT PLT.❑ /r_ r spou1 <br /> Method of D' <br /> Drst•nca to nearest: well, 6 �OUndal:nn_�,� Pfoi emy lirw <br /> LEACHING LINE R No.&Length of lines _ til(, lot:l length/sus- r <br /> FILTER BED CI Distance to nearest: Well _ Foondatan. � Property Line _ <br /> _L <br /> SEEPAGE PITS to Depth ' 3 <br /> .-��. Siis ��r) Number_ n <br /> s" SUMPS U Oatartu to nearest' WWJC`� Founostron XL' Property fins <br /> DISPOSAL PONDS O <br /> 1 hereby eert.fy G.at I have prepared this appl.calwo and that the wort w o be dune in accordance wt h San Joaquin County ordinances,state laws,and <br /> rules and regutatwre of the San Jo.,ouin County <br /> Home owner or IKereM agents s.pna' 'a csndes the fonow,ng."1 candy to i in the performance of t.N work lot which this pwr l k a;.u+;,1 chars not <br /> wnp"any person in such manner as to Deco-.e subject to workman's compenaati,)n taws of Cal.:o.raa"Zontrsclor's Awing of subcontracting signature ' <br /> carotis the follow":"1 certify that in IN-Wcfmsnce of the.vt..k 10,which this permt.a.seWd,i shin empiny persons subject to workman's compenGL <br /> tion taws of C410..1nis.•• .., <br /> The applicant maty}/M Iw as repu+�.Iynslp�ectionj.Comr:e/e drawwp -nversa saw. <br /> Signed X .�r�/fCT-' s!7`�t�-- Tr.N: —_G:/ •//) - -- -- Data: ALT-/57 -4. <br /> FOR DEPARTMENT USE ONLY ) <br /> !Applc.atrori Accepted by VLA n <br /> _ Data lr Aa f <br /> tom ,Z �[�p►� <br /> r .W Grout Inspection by ate.y F.r.ai Inspecwnn by Cate,�,�-s--�/ <br /> AOOitioMr Ccerwrentc: _...�Z.IC_49�� <br /> Appi4.rnl - Return all ^uptee to: San Joaquin County Putillc health S,r.lces M <br /> ' Snvironwental Health Perolt/Services <br /> 445 N San Jcaquln, P O Bo. 2009, Sci.n, CA 95201 <br /> sfE AM.`tiNT DUf AMOUNT REWTTEO R;CEIVED may OATF PERMIT NO <br /> i.10 CIA�$M <br /> 1.c t,N latY ...e. o P", , w T a , -24s'71 <br /> 1."39 F- <br />