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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> KNVIRONriENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)488-3420 <br /> P 0 BOX 2009, STOCXTON, CA 95201 <br /> PEf{�IIT tiXPIRFU 1 YEAR PROP DATE ISSUED <br /> (Complete in Triplicate) <br /> Appllcatloo 1s hereby cede to San �oaqui0 County for a peralt to construct and/or Install the work herein described. This <br /> application is aside In casyllance with eon Joaquin County Ordlnance Ito. 169 and Ift2 orad the Rules and Resulatlons of epn <br /> Joaquin County Public Health Services.. �/ <br /> Job Add,pis --��si""L�— -------- City /'S'�_ t Site/Acreage <br /> Owner's Name/JGA/ �!y _. _i_1//.�L.YYd�dress 7Lj1f�_ �� —^ Rhone --- <br /> ConlUtla_-/_ L41l=f� 41�-I..._ Addult /-�_QL_�YT.. ./ /1�"� - l�tsnE1 No. <br /> _YPI OF WELL/PUMP N(W Wfll (1 Wilt RIPLACIMINT (I DISTRUCTION I 1 Out of Pervice Well Col <br /> +� PUMP INiTALIATION I SYSTIM REPAIR (I OTHIR fl Monttaring well (� <br /> DISTANCE TO NEAREST SEPTIC.. TANK .__-.__--_— 4EWIR LINES -_r_ _. nl%POeAL OLD _ PROP LIN4. <br /> FOUNDATION AGRICULTURE WILL ,._ OTHER WELL PITS/SUMPS ail <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Industrial U Open Bottom n Manteca Dra of Wee Eecavetron _ Du of Well Casing <br /> f I DomesticrPnvus LI Gravel Pack (I Ttacy TVoe of Casing- Specifications <br /> 11 Pubtic 1 1 Other I 1 Delta Depth of Grout Seal _ Type of Oroul_ <br /> I I Ingjdtwrn Aptwni, Danlh 1 I Owern SurfaN Seal Immersed by _. <br /> Rapee Work tions 11 1rye vl M„n.E; --- --._ H P E111e Werk Dwle -- <br /> W/E Detfluefon 0 WIN Olatnsfu peellitS Ilaterl” 6 Ogth <br /> Depth Pillar Material f, Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I INo seplr0 system pernwlted of ptrbtrc sewer so <br /> . available wethrn 200 lost.) <br /> Installation will serve: Residence r/Commercial_ 011,w <br /> Number of Yvmg units: L Number of bedrooms 3 <br /> Character of soa to a depth of J feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Dr 4- d Caw" No.Complimmoo is <br /> Pli TREATMENT PLT.O Method of 01-; <br /> Distance to newest We11/92CL_r_ F_oundatron + Property Line d <br /> LEACHING LINE No. 8 Length of lines Total Isngth/slie <br /> FILTER BED ❑ Distance to nearest: Wed/CA'OlTs"Foundston-AAA!=Property Lko <br /> i <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS 1.1 Distance to nearest Well Foundalron_ Prpperhy L" <br /> DISPOSAL PONDS I.l <br /> 1 hereby candy that I have prepered this application end that the work will be done in accordance with San Joaquln county ordinances,state taws, and <br /> rules and rogulolons of the San Joaquin County <br /> Home owner or licensed agent's signeturs certifies the following:"I Certify that sin the perlOrmanCa Of the wont Id which this permit N oeswd,1 shall not <br /> } employ any person in such manner as to become subject to workman's compensation laws of California."Contreetor's hiring or sub-contracting signature <br /> certifies the following:"1 certify that in the performance of the work for which this permit is issued.I shall employ persons subject to workman's eornpensa• <br /> -ion Laws of Cdiforria." <br /> The applicant must can Ior requrt ns t m. Complete drewing on reverse aide. q <br /> Signed Je�yAC�`_ Title: dmmzzibt. <br /> Date: g::jft <br /> / <br /> F EPA ENT USE ONLY <br /> Application Accepted by --� Date ea=;lir <br /> PH or Orout Inspection by Date Final Inspection by Oate <br /> Additional Comments: <br /> Applicant - Return all copiea to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 446 N San Joaquin, P O Bos 9009, Stkn, CA 96901 <br /> INFO AMOVNT DUE AMOU REMITTED CA H �1 <br /> /1471111VIDD By DATE J)� PERM11 NO. <br /> . IM t)N 1PIEV 11+I1 s1J // • 00 <br /> IM 1r� <br />