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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT XPIRES t YEAH PROM AATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Instal! the work herein described. Thi■ <br /> application is suds in compliance with San Joaquin County Ordinance No. 5li9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Jot,Address �o S5� F/'/SR EE __ City—Az-- _�'Ex"l t 51se/Acreage <br /> ' Owner's Name TACti W llO i7 Address sxzlx"E Phoria <br /> CcnhbClor FLO'//J Ly/GG/J Address .[ WD-ls .B��i TIE Licenze No. ,5�JT7-7G phone '�'6� <br /> TYPE Of WELLIPUll NE'W WELL U WELL REPLACEMENT O DESTRUCTION G Out or Service Well L`. <br /> PUMP INSTALLATION 'J SYSTEM REP OTHER C Ibnl tering Well C� <br /> DISTANCE TO NEAREST. SEPTIC TANK SE R LINES ..— DISPOSAL FLD. PROP. LINE _ <br /> . FOUNDATION __, A_GR: LTURE LL OTHER WELL.__— PITS/SUMPS <br /> 'INTEND EO USE _ TYPE OF WELL PROBL EM AREA ONSTRUCTION SPECIFICATIONS <br /> Il Induotnel �U Open Bottom n Mameca ie. of Well Excavation�__� Ds. of Wall Casing <br /> ' U Domestic/Private EI Grovel Pack 11 Tracy Ty of Cea.ng,_e______.__. Speciicalions - <br /> D Pnbhc Cl Other U D s Oepl DI Grout Sea Type or Grout , <br /> CA Inviter, Apprtl Depth Eastern Surfic Sou' InstalWd by <br /> Repor,Work Oa» U Type of Pump H P. $late Work Done _ <br /> Well DoFlruction D Well Dismalat Scaling Material Depth r" <br /> Depth Filler Materi 1 i Depth �^ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPA.RIADOITION Cl. DESTRUCTION G INo sapnc syslem permitted d pubhc sower .s <br /> '- wadable yl lhm 290 feel.) <br /> v - <br /> installation will MNa' R{a.//tlenCa Z commercial Other <br /> Numbat of kv.ng unit*. —L Number of bedrooms -_.� a <br /> Character of sod to a depth of S feet. S"A.r/l� Y L �A�7 _Vil table depth <br /> SEPTIC TANK I Type/Mfg. G 11 C{paoity 166§7 _ No. Comportments - <br /> PKG. TREATMENT PLT, 01 Method of Dsposat <br /> Aatance to.4,nC Well ,CO Fnundal:on_.E., Property'LiAO <br /> 6r / <br /> LEACHING UNE .q. No. 6 Length of linen- ��1� r Totbl length/size 3.;ta r <br /> FILTER BED ❑ Dstanca In nearesT- , well 1061 t- Foundation �'/'7" PtoPanv Line /r+' ' <br /> SEEPAGE PITS if Depth _ _ She ~� _�. Number ._:. _ _ <br /> SUMPS Ll Distance to nearest Well Foundation -Property Ler» I$ <br /> DISPOSAL PONDS 0 <br /> I hereby conify that I have predate mit aoditation and that the work wi l be done in occordance wiln San Joao LLD, county Ofdin ances, slate lam, and <br /> ' rad and reguraoons of the San Joaou.n County <br /> Nome owner or iconaed agent's a<gMlure candies the fotlowmg: 'I cattily that .n Iho 0e,101mdn Se Of the work for which this palma is.Slued. I sNll not <br /> employ any Fusion,.n ouch msntu as to become subtect to wotkman'a componsati0n laws of CUilom=s."Contrectoi s mnng or slab-conpacting agnatme <br /> certifies the following: "I csn.ly that in IN pedonmancs of IN work for which this porm�l is rssue4 t shall employ pe.aons subject to workman's compensa- <br /> thin lam of Californla." <br /> The applicant must all for all raou.rod inspa`cliom C plata draw:ng on rover" tide.s� 4 <br /> Signed X � f / Tale: /,h' Dale: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by -}i O Off' Date <br /> Pit or Grout Inspection by ,. Data Final Inspection 5 <br /> Additenol Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2000, STOCKTON, CA 05201 <br /> FEE AMOUNT DUE AMOUNT AEMITTED `K RECEIVED By DATE PERMR N0. <br /> rNfoCA5H <br /> fH"liv <br />