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APPLICATION FOR PERMIT ( ] <br /> SAN JOAQUZN COUNTY PUBLIC HEALTH SERVICES; _ <br /> ENVIRON ZUTAL HEALTH DIVISION <br /> P O BOX 2009 , STOCKTON . CA 95201 F l� `'f Ill K: <br /> (209) 468— 3420 <br /> TS I <br /> (COIrtPlete ' ia Triplicate} ;; y ,­i <br /> APP=:c-lon la hereby reads to <br /> SILO Joaquin •! <br /> LpPlicss,lo❑ fa made in c Q County fora permlt to construct and/or install the work herein de:scrtbed. This <br /> Lith Sorg ylth San Joaquin County Ordinance mo. 529 and 1862 and the Pules and Regvlatlonb of Sun <br /> a County Public Health 9erYlcaa. <br /> 0o detest Z C11 APN /1_1r-4a,!:1 - 23 rr t <br /> �] City Lot Size/acreage 1!Z I <br /> n.n'ner'r Name Address 1•Q• Q}` tea J �fn�r 9s _ _. c; <br /> Phone G-.s77/ <br /> Box le.Z,2ra <br /> AddressPhone 91 <br /> 'YP: OF WELLIPUMP' NEW WELL O WELL REPLACEMENT (-.1 PUMP INSTALLATION ❑ DESTRUCTION Cl Out of Service "Voll': 0 <br /> ;ISiANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR " OTHER Honicoring,,"I,- <br /> SEWER LINES 1a SO r/ y/A�lca <br /> FOVNQATIQN —�—� DISPOSAL FLO,✓/�_ PROP, LINE �S •-_ <br /> _ AGRICULTURE WELL IVJAI _ OTHER WELL LD PITS/5UMPS j�± <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i tnaustrif ❑ Open Bottom ��� <br /> D Manteca pia. 01 Well Excavation Dia.-o! WaIE Casing <br /> ❑ Gravel Pack 0 Tracy Type of Casing a C <br /> -° �<<blic ftirTOthorSpecifications /1/64 ` <br /> t ❑ Delta Depth of Groul Seal �^ /C .1 G am__, Typo of Grout A <br /> App(0)L. Depth C) Eastern <br /> $urlace Soul Installud Ov... ] <br /> 7 t.oair wort Done L3 Type of Pump M.P. . Stou work Dona _ <br />.Ycu Oersruction C Weil Oiemeter Scaling X&tcrlal L Depth 1 <br /> D,pth Filler Naterial i Depth ` _ <br /> 'YPE OF SEPTIC WORK: NEW INSTALLATION Q REpA1R/AfjOiTION ❑ DESTRUCTION G INo se tic s slam <br /> P Y permitted it public sawar is <br /> In$(SI4tiCn will "rve: Recidance _ Commercial_ Other available within 20D Iset.l <br /> l= <br /> .NumO*r of living vnils: Number of bedroom-& <br /> Chsracter of axil to a depth of 3 feeC <br /> ZPTIC TANK ❑ 7ypalMtg _—Waler table depth <br /> Capacity_�� <br />'CG. TREATMENT PLT, � •--- No. Comoartrnants <br /> Distance to nearest. Well FovMethod of Oisposal'ntlulion <br /> Property Lina <br /> 'ACHING LINE Cl No. 6 Length 01 tines <br />:,�Ti:R BED � Intal Iangtn/si¢e <br /> (1 Distance to nearest: Well Foundation <br /> ._._..... Property Line <br /> ScEPAGE PITS 11 Depth <br /> S+re �--� <br /> SUMPSNumberCl Oistanca to nearast: Well <br />]ISPOSAL PONDS -- .Foundalign�� Property Line <br /> 0 <br /> noegoy certify Incl I have prepared this application and that the work will be dors <br /> ries snd regulations of the San Joaqvin County o in aa:nrd;,n[a with San Joaquin county ordinances. stain laws, and <br />- <br /> lom0 owner Or "canted 09enl'a signature certifies the following, ­I certify that in the Ponormanee atMework for which this parmil is issued, I shall not <br /> antploY arty Darton in such manner as 10 4QGgme aubliact to workman's eompansation laws al California.,, Contractor's hiring or sui)•COnut,�tinq siQnalu,e <br />:arj"as the following: "I cattily that in the <br />;ion {iws f Performance of the worts for which this permit ie iaauud. I shall employ parsons subject to workman's compansa- <br /> o California. <br />:he spp.'can( cath d inspections. Complete drawing on reverse •ids. <br /> TitleDaFORDEPARTMENT' USE ONLY.Ooficstion noted <br /> Data LZ46 J ' Aran <br /> or Grout Insp•action by <br /> Date Final Impaction by <br /> Dete <br />+tltlilipnef COmmanti: '� ' <br /> 7'-:Cd L - FIOL4rA tJ� copies for SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SSttVICES <br /> 445 N SAN JOAQUIN. P O UOX 2009, STtKKTON, CA 85201 <br /> FEE AMOUNT DUE AM C <br /> tNiO AMOUNT REMITTED Fl RECEIVED BY <br /> DATE AEAMIT NO.-;i. k <br />