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APPLICATION FOR PERMIT ��pp <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S VI•L A 1 <br /> ENVIRONJIENTAL HEALTH DIVISION /n���n 4'/�� <br /> 446 N SAN JOAQUIN, PHONE (209)468 4j8r � "J <br /> P O BOX 2009, STOCKTON, CA 9520L FAC # <br /> (Complete in Triplicate) <br /> Application is bemby ade,to Sao Joaquin County for a permit to construct and/or ioatall the vork berela described. This <br /> eyplloation Is made 16 co plijAn a with San Joaquin County Ordloance No. $19 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> S','/ <br /> Joh Address _I��so .{'OT�%S /�.�0�_�d- city R/dei✓ Lot Size/Acreage '2C4 s— !Sb-3'f <br /> Ownr•sName -- - 0bd f - AAd;si if'1'SO.Jfji-IQi�►oX'-lIP PHorrr--�4-l--dE.D" - <br /> Contracts AIIZho -6556" Address dfOO y�84 <br /> License No. / Phones <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service all <br /> _ LT- <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well D <br /> DISTANEE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECT I \� <br /> n Industrial O Open Bottom D Manteca Dm. of Wall E,cavation fAITIRMT ora. of Well casing <br /> C.1 Dortaetic/Private D Gravel Pack O Tracy Type of Caarp_ R D Specihcatwns <br /> I'I Public 1�1 Other fl Doha Depth of Grout Seat 'L Type of Grout <br /> I I looption _APproa. 1 I Eaatrn SuAsu Sssl Installed Vi <br /> Repair Work Oone U Type of Pump H.P. $AN1Jpq(�V)I>t,�pUNTY <br /> Wall Desavctlon ❑ WaY Dwr~ Sealing material a�DpekpDl LI �""'� <br /> Depth pills material a Nepstt) <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION A REPAIR/ADDITION f I DESTRUCTION I I (No septic V$I*m Permitted itpbkO <br /> I avallNNe within 200 lest.) sower u <br /> 1Mtauawo will W" Raaidana-L.�;ComnarcW_ Olhar <br /> Nurturer of living unit: 1_ Number of badrorrm <br /> Chanson aoa w•depth of]feet: SA/vd Wat;teat depth \ \\ <br /> SEPTIC TANKK Type/Mfg PMO CASA t L Capacity /600 No. Compartments <br /> PKG. TREATMENT PLT. C:) Mettlod of Disposal <br /> Dimanes to nearest: Wel Fotedstion ACI Property Line -4e0' <br /> LEACHING LINE 0 No. a Length of lines Total length hire ��O ,O <br /> FILTER sED G Distance to matat: WON BOO ' Fourda ion AO' Property Lkta A00f h <br /> SEEPAGE PITS I I Depth Sire Number (\ <br /> SUMPS LI OMance to merest: <br /> DW401 Foundationn <br /> ISPOSAL PONDS ❑ Properly Line <br /> hereby certify the( I have prepared this apPYcslion and that the work will be done in accordance with Sen Joaquin county ordinances, stats laws, and , v <br /> rued and rliquishO s of the San Joaquin County vv/ <br /> Home Owner or bcarMW"era's eipnature man fin the following: "I Certify that in the performance of the work lot which this permit is nsuad• I shell mol <br /> employ any Parson m aur:h manor as to become subject to workman's compensation laws of Calilornia." Contractor's haring-or sub-contracting signature <br /> certicert f4We Of f�f :1 Artily that in the pedomwres 01 the Work for which this Permit is issued,I shod employ persona subject to workmen)corriWnaa <br /> The Mpkam matt Y for M tquied kapaqtiom. Compete drnwng on never" side- <br /> Some Tela: Cearb-,ecTer <br /> Data: _S-Ri - 9y <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted pry <br /> Dots 4Area _Zia __ <br /> Ph or Grout Inspection by Oats Finis Irrpeconn by Dat /y <br /> Additional ConrrrntT — r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> 11 <br /> Environmental Health Permit/ServiOee <br /> 1 <br /> 446 N Ban Joaqufe, P O Boa 2009, cotka, GA 98201 <br /> r <<Q AMOUNT DUE AMOUNT REMRTEO K H RECEIVED by OA7E PERMIT NO, <br /> 1. Iyts IAEY.11.1) 1 U6 <br /> S <br /> to u / 7 <br />