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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC M6,LTH SERVICES <br /> BNVIROnfKRNTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PEONS (209)488-3420 <br /> P O BOR 2009, STL"TON, CA 95201 <br /> PERMIT EZ21R .S 1 YEAR PR DATE ISStl_F.7_ <br /> (Complete in Triplicate) <br /> APplleatiao 1. hereby Bade " San :oaquin Cdunt y for a permit to construct and/or install the work herein desaribod. This <br /> arPllcatien Is same in ccsplttsee with Sar. J,4squln Cr�mty Ordinsnee No, 549 and 1862 and the Rules and Reculrtione of San <br /> Joaquin County Public Health SSamices. <br /> Job Address r •(/�;1 C-.f-`-i_�/.tc1/ aa <br /> cay45`a.L4,nr_ Lnt sit+ .icrn�e —— <br /> Owner"t Name ` ,}�y�1��;=nAddress L� !`!7 E 4[ 1t[ PhMe 'rl <br /> Conlraclo, � " �L—Address /��7_�L;1V jJf_2A2-L,Cenie No. 0_Pnone <br /> ,i TYPE OF WELL! UN1 N:W WELL C WELL PEPLACENEN. 1-1 DESTRUCTION Ll Out of 8ervlco ifell <br /> PUMP INSTALLATION O SYSTEM REPAIR C7 OTHER oe Motitoring Voll � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ __ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ACRICULT'JREWELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PA03LFM AREA CONSTRUCTION SPFCIFICATIO11S <br /> ❑IndustnN ❑Open Bottom CI Manteca Dis.of Wall Excavation 04.of WIN Cksing <br /> 9 Oomettic/Private C1 Grsys!Pad ❑Tricy Type o'Cas".. Specificaons <br /> I'I Pio Dic f1 Otho fl Delta Depth of Grout^4e1 Type of Grout <br /> :i 1 I;uiUatron _Apfwol. Depth I 1 Eastern Surface S I I sfarad by _ <br /> i Flow Wort Done 16 Type ri Pump ����[[���FF H.P. � i L State Work Done sea-( <br /> Wee Dmintction ❑ Well Ownater +" wins Material i Dr)th.. .-y/ ,l. �., M r <br /> � <br /> mn Owl, 12-07" P44tev <br /> a <br /> Ttt OF SEPTIC WORK: NEW INS-rALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I Iho septc system pcemrttad d pudic sewer IS <br /> 1 wadable wahin 200 to".) <br /> '• Installation"conA: Residence_ Comfnercisi_ Other <br /> Number of fivirg units:_ Number of bedrooms �� M A/ Lr� <br /> Cherectm of sort t,? a a dacth of 7 few: Water table <br /> h—jl <br /> SEPTIC TA;lK O Type/Mfg Cap+city No.Compsrtmants <br /> M <br /> i PKG.TREATUF,, PCT.❑ <br /> Method of Disposal <br /> Distance to nearest: Well Fourvfetiri, Proptry Lino <br /> i <br /> LEACHING LINE ❑ No.C length of::. i Total length/sire-yY. '� <br /> y FILTER 8ED ❑ Distarnca to realest: '/k's0 Foundaborr, property`I(y+�Gl Y Ger <br /> SEEPAGE PITS 11 Depth Siva Number 't' 7 1392 _ <br /> >? SUf.I:S LI Disurnce to noanst: W'aA Foundation PropaRyFffin� �iNT'/ <br /> L DISPOSAL PONDS ❑ lm',, sr N . . c_RVICES <br /> !; I hereby certify that I hove p+pared thk apphcat,on a:xl that the work w,4 be done o accordance w=}it�..� W 66Jn Y, 1 to laws,nntl <br /> rules end reguislam of the San Joaquin County , <br /> troms owner W licensed agent's signature cartrfie,the following:"I cerrty that In the ppfGrmance of the wMr for which thus psn, 1s eats f She not <br /> ampby any person in such manner as to become subpct to workman's compansatran laws of California.'•Contractors hiring of sub-contracting W"ture <br /> C"S" <br /> the foscwr a NI cwufy Wt n the pettamance of the work for which this perm's Is towed,I roll employ poroone subfect to workman's con w4ma. <br /> The applicant rtant call fd required nspeciions. Compete drawwng on reverse fide. <br /> Srpncp 7L t0 1st. ! ^� T;tle: Dow <br /> a <br /> FOR DEPORTMENT USE ONLY A//� <br /> Application..ccepted by /r <br /> Pit or Groutlnspsction by Date Final Inspection by - batt <br /> Addroonal Coervnenta: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services der <br /> Envlronnental Health Perslti,�ervices <br /> 445 N San Joaquin, P O Dox :DOA, Stkn, CA 1,3201 <br /> FEF I :wVOUNT!t ASAOUNT REMITTED <br /> ,NFC K A�iC[0.'ED aY <br /> CASH OA" PERMIT 40, <br /> .EM rile Ilt[V.rrxv -fl, yLrQv . <br /> [)t,471 /✓ J 3_>� � '2 5 7_. <br />