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<br /> APPLICATION FOR PERMIT
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<br /> yg; SAN JOAQUIN COUNTY PIBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVIION
<br /> ieVi E, HAZELTON AVE. , PHONE (209)466-3420
<br /> E p u BOX 2009, STOCKTON, CA 95201
<br /> SIT EXPIRES 1 YEAR FROM DATE ISSUES
<br /> (Complete in Triplicate)
<br /> made to San Joaquin County for a permit to construct and/c: install the work herein described.-,-'`'IRt1e .. �, ' 7•
<br /> A 1lcstioa is hereby 9 f San
<br /> PFRegulations o
<br /> " r application IS meds in cot�q?llante with San Joaquin Cnunty Ordinance No. 5)+9 end IB62 and the Rulra and Aegu a ,g " ��,-f„•" '
<br /> Joaquin County Public Heslth Servicea.
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<br /> r -. . City
<br /> 1 Lot Site/Aereugeqtr f�..
<br /> 't Job Add;ass
<br /> LL o Yn I'1 1 tJ_P} Address 'J r\N� J phone A�Z 5 f qµ
<br /> Owner's Name )'l" +' '
<br /> ,t!vaCk {�t�'•, `-�' Address ��L1tilGuT 'f _PhoneL
<br /> Contractor _^! License No.
<br /> TYPE OF WELL/PUMP: NEW WELL CJ WFLL REPLACEMENT �.1 DES:RUCTION.❑Out of,ServicerXeil Ll a -
<br /> ¢
<br /> OTHER G Monttoring well ❑ tib? �'
<br /> t PUMP INSTALLATION SYSTEM. REPAIR 0 a t"
<br /> s DISPOSAL FI.D. PROP LINE
<br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES
<br /> q FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS
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<br /> PROLEM AREA CONSTRUCTION 5!£CIFICATIONS f)la of ! r 6 } 4.�F A',',.
<br /> INTENDED USE TYPE OF WELL s Welt CaainB
<br /> CManteca Oia.of Well Excavation' ❑Open Bottom Cl industrial
<br /> J•x $peaifir atlorta r a`" +}� � '+f �{ds n^,
<br /> VDomest;c/Private ❑ Gravel Park ❑Tracy Type of Casing ,
<br /> I:1 Other �1 Defra Depth of Grout Seal Type al Gruut {{k ,
<br /> k - I I Ptrbkc 1 .:-' yx rgwy FeZ '3Wi'a
<br /> lrri anon —Apptoe, Depth•,,.t I Eastern . ;Surface Seal Instaflnd.bY
<br /> e D ... 1 J/} State Work Done�'�`A 1.S t Pl 1 c7��_-, e ,,. �'! -if g;:F,•�
<br /> s C!Ja n M.P.
<br /> Repair Work Done J, Type of PumP..4 -- - ! Y ' /�t "C '-
<br /> >., ,;,;,. x ' 'Pump
<br /> - - Sealing Material i Depth / .
<br /> f + ` Well Destruction L]" Wel[Diameter
<br /> peP[h Filler Material i DeptA
<br /> TYPE OF SEP;IG W7FK:• :+EW.NSTALLATfON I 1 REPAIRiAODITION I I. DESTRUCTION I I iNo septic system neem n �t•pubt�e sewer isntFs? -�',
<br /> a2it {p.
<br /> evadable within 200 Ieet t '3* skr,rt5- �� WMTF—
<br /> s� --. _
<br /> h . - Installation will serve:„Residence Commefcial Other
<br /> Number of living units:« ,Number of bedrooms
<br /> R Water lebfe depth
<br /> Y `
<br /> Character or=A to a depth of 3 feet:
<br /> SEPTIC TANK.'.'. "G. TypelA6lg F Cspaclry No.f crttpartments k y� �q t
<br /> `� Method of Disposal
<br /> PKG:TREATMENT PLT:G7 �,y rsry 1 ka *
<br /> Distance to nearest:
<br /> Well
<br /> Foundation Property Lrne s ) . sem i
<br /> iv,TrX .
<br /> Total lengthlslre {• - 1 i x¢�
<br /> LEACHING LINE" ❑ No.f!Length of lines -- -•Property Line - •'" s4 -tom .�k { wwf ��w
<br /> FILTER BE l.3 .Distance to nearest: Waif _ Foundation - 4,F,•�h ,�,,� i;, �, ,
<br /> =SEEPAGE PITS�: 1 1 Depth _ _•Sire ,Number -Y .y a",,
<br /> s,` S r r Lot,/fit SUMPS LI .pistance to nearest: Well Foundation Property Line y ' ' A-
<br /> 777
<br /> rh-kd�b Y aZ+
<br /> -%t ,�.5 1•✓a„r 4 DISPOSAL PONDS ❑ - {
<br /> hereby certify lhat I have prepared this apokcation and that the work will be done in accordance with o fn Joaquin county ordinances state laws ands ��* > .�
<br /> g wYrr -' 'n•'ss an[rege.rations of the San Joaquin County
<br /> �f* "� " .
<br /> Jt ,, �?! _ Homa pwryr o.'airensed apen['s signature Certifies the fotlow�ng:"I cenify that in the performance of the work for which this permit is esavad'I shall
<br /> R ,rR'# -,employ any person in such manner as to become subject to workmen's compensation laws of California."Contractor'!hiring or tub-contraCUnq eignatwe
<br /> ".ry. _employ
<br /> the p aowinq:"1 Certify that in the performance of the work for which this permit is issued,1 shell employ Persons subject to workman s compensa
<br /> l., }"cM'x 4+ •t+ renis l:ws of California," - a., rvtr '; -r• c yq(ti,,,,,J ATF
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<br /> 'The applicant mut: !for all required inspections.Co i I lets drawing on
<br /> Date:
<br /> x Title:
<br /> Srgnsd * �t 5
<br /> f
<br /> _ Date .Area
<br /> Applicatlon Accepted by W
<br /> :tom y
<br /> Pit or Grout Inspection by Date Final[ncpection by Deu7 V
<br /> Additional Comments:
<br /> f ApylSceot - Return all copies to: San Joaquin County Public Health w `A.»6
<br /> services, Envirauskntnl Health Permit/Servicea:
<br /> 161)1 E. Hatelton Ave„ P 0 Box 2009. Stockton,:CA 45201
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<br /> .-ZE AI+tOUNT nEMtTTEo CK• FIECEIYED BY _ DATE ' PC IT'ND t 4 1 l
<br /> a AMOUNT DUE CASH -
<br /> 5 - INFO
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