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ti.. <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Err V I RONMENTAI, HEALTB DIVISION <br /> 145 N SAN JOAQUIN, PHONE ;200;453-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> PEJL lT , IRES 1 V4AR FkOid DATE T_SSU <br /> (Complete in Triplicate) <br /> Application is her made to San %,:jula county for a permit to construct and/or install the cork herein .te,.,rlbed. iris <br /> apyllcaticn Se rade in cllance r�tn Ser. 7w�utn County Ordinance No. 549 and 1962 and the Rules aaG -'`[u]e!i^ns of S. <br /> JoWuia County Public Health Services. <br /> tr_ lob l t/�' `/;r( Lot Site/Acreage <br /> L;-o 7 C.1 <br /> Address oz"/ Phonu�l / 11? <br /> 6G,5 <br /> 1(2 License No. / Phone � <br /> Q <br /> Ad dress <br /> YPE OF WELL/PUMP OTHER ❑ µons tori na <br /> NEW HELL is WELL REPLACEhtENF E1 DESTRUCTION Out of Service Well <br /> Cl <br /> PUMP INSTALLA'•:ON G SYSTEM REPAIR Cl <br /> DISPOSAL FLO. PROP. LINE _— <br /> am. DISTANCE TO NEAREST_SEPTIC TANK SEWER LIVES _ -AGPICULTUQE WELL _— OTHER WELL PITS/SUMPS <br /> " <br /> FOUNDATION _--- <br /> INTENDED USE TYPE OF WELL PrOBLEM AREA CJNSTRUCTION SPECIFICATIONS Ou ul We"Casing <br /> i'1 Industnd ❑Open 0 Manteca Die o1 Well Excavation Spm c.ficatans <br /> Type of Casing___ <br />_ r y Oomest.CIPr,vsle ❑Gravel P.ck U Tracy Jepto of Grout Seat �.-- Type of Grout <br /> i ub6C <br /> Il Other I 1 De!ts <br /> • I un0aticn __ApProx. Deplh 1 Eastern S.:rlece Sell Insu':eC hY <br /> HP —_ State Work Done— <br /> Repair Work Dor U Type of Pump Katerial A Depth <br /> Seal:rel <br /> Well Destrrcron Well Diameter <br />� ( 1111er Material A Depth �_.-------� <br /> Depth <br /> available-,thin 200 Iso..) <br /> TVpE OF SEPTIC'WORK. NEW INSTA_�ATION 1 I REPAIR/ADDITION 1 DESTRUCTION I I [No sepuc synem perrtuned i psi K N <br /> Inatatlat\ion Wi11-serve: Residence_ Commercisl_ U[r.er <br /> Number of Irvingunits: <br /> Number of bedrooms _ I,Isbls Lspth <br /> Character of soil to a dawh of 3 fe No.Corrlpartma.nts <br /> SEPTIC TANK O Type/Mfg h-- —�CJ � <br /> �. Method of Disposal <br /> PKG, TREATMENT PLT.Cl Founder. Property Lina <br /> Distence to nearest: ell _.1 <br /> Total Iength/size — <br /> LEACHING LINE C1 No. &-Llrsgth of lines - <br /> FILTER BED l:-�{lstanc..to nearest: WeII <br /> found+tian _ Property Line <br /> Sin Number <br /> bEEPAG�E Pl <br /> II Depth P,openy Line <br /> SUMS 1.1 Distance to nearest: W!II— <br /> Foundanon <br /> 0;OSAL PONDS ❑ <br /> I hereby certify that I he"prepared This application and•.hat the work wdl be done,n accordance with San Joaquin county ordinances,slate laws•an <br /> ruses and regulation of the San Joaquin County <br /> Home owner or ticensed agent's signature certifies the lollo—rig:"I can.a•mat.n the performance of the C nt tot which this ractor'$hiring fsrrtvt O issued,I shag not <br /> employ any parson,n such manner as to become subject to wOrkman'r -.mp Ih,s per it,% $s ed,I hall employ persons subject to ofs,man'sc�,.nu <br /> employ <br /> s the following:.. cemty that in the pertormanre Of Ine work lot which this permit,%.saved, <br /> canifi <br /> rion taws of Celirom4.'• <br /> The ePPlictnt etc tall is U.�p,i�s �iogs.Co pie �ew.^.g on <br /> 1� <br /> SiOned I/ <br /> OR DEPARTMFYT USE ONLY <br /> Z <br /> DAro <br /> Date <br /> — — <br /> I <br /> Application Accepted by �+/�t;� Date <br /> r Date '._�—L—J-F- Final Inspection by-�— q <br /> Pit o<G a Ina tan by ! / <br /> Additk"rtdmments: <br /> Arplicant - return all cops es to: gwironmokqan talIn nNealthunty u Permit/Services blic li�aith ices <br /> aa. <br /> -0i5 N San LAI stealth <br /> P O ❑ax 20•19, S[kn, CA 9520 <br /> K RECEIVED by DATE ►ERM0 NO. <br /> FEE AN.DUNT DUE AM^,i1NT REMITTED CASH —' <br /> INFO 0/;2 <br /> J.11-14 IREV.v.s.L r <br /> ax. <br /> a..r <br />