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APPLICATION FOR PERIAIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT <br /> . ENVIRON Z,$TAL HEALTH DIVISION RECEIVED <br /> P O BOX 2009 , STOCKTON , CA 95201 <br /> (249) 488-3447 JAN 19 1993 <br /> R NJ0RQEIIN COUNTY <br /> (Complete in Triplic&te) ENVIROLIL; H ' HEHASfTRVICES <br /> pplice,tlon is hereby made to San Joaquin County far a Permit to construct and/or install the work hertitT >��u Thla <br /> pplicstioa is made in cc=plianca vlth Sus Joaquin County Qrdinance No 549 and 1862 ►ad the Rules and Regul--"one of 8sn <br /> oaquin County Public Health Seryices r h <br /> sb Address /OQ 2f0 City 5TOCl:=1J Lot Size/Acreagr <br />.+rnrr s NameL FA) Imo` Address � �i° ?hone Z 7� <br /> /� Z.523 RI&JLe RG.av G70 PhoneAS.3 -$74.7 <br /> ontraclor�STLRf3EF2G�STcddR1~ Address n License bio - <br /> fPE OF WELLIPUMP NEW WELL ❑ WELL REPLACEMENT DDESTRUCTION ❑ Out of Seryica Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER monitor-Ing <br /> Salmi 430.112riv4,5 <br />'STANCE TO NEAREST SEPTIC TANKZ,:;Z)' SEWER LINES 2-J50r DISPOSAL FLDNZA PROP LINE 45 - <br /> FOUNDATION -Lf-r- AGRICULTURE WELL &Zh C)-,HER WEII�� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Ota of Walt Casing- C, <br /> DomesticlPtivate ❑ Gravel Pack 0 Tracy Type of Casing ° Specifications i <br /> Public EX other CO Delta Dr-lth of Grout Seaf Type of Groul��f�gr��n�L-. <br /> ImUiuS <br /> on �_Approx Depth ❑ Eesrarn Surface Sail Installed by o nLcncfo r <br />,psi( Work Done D Type of Pump N/A H P State Work Done _ <br /> ail Destruction ❑ Well Diameter N11A _ Scaling X&t'ariel & Depth <br /> Depth Piller katerial L Depth <br /> CP SEPTIC WORK NEW INSTALLATION LREPAIWADOITION Cl DESTRUCTION C1 (No septic system permitted if publ,c sewer is <br /> available Within 200 feet f <br /> Installation will serve Residence Commercial — Other <br /> r <br /> Number of living units Number of bedrooms - - <br /> Character al sog to a dspth of 3 feet Water table depth <br /> PTIC TANK ❑ Typ+r/Mfg Capacity_ No Compartments <br />.G TREATMENT PLT q Method of Disposal <br /> Dtstanca to nearest Wall Foundation Property Line <br /> ACHING LINE L-) No & Length of lines Total length/size <br />,.TER BEO ❑ Distance to nearest Walt Foundation — Piopuny Lino <br /> EPAGE PITS It Depth Sue — Number <br /> JMPS LI Distance to nearest Well Foundation Property Lina <br /> SPOSAL PONDS O <br /> sereby contfy that I have prapared this appitcauon and that the work will be done in accordance wish San Joaquin county o dinarcas staid laws, and <br /> les and regulations of the San Joaquin County <br />)me owner or licensed agent a signature certifies. ilia following I csnd'y that in the performance of the work for which ihts perms[ is issued I shall not <br /> tploy any person to such manner as to become subject to woriimen s compensation laws of California Contractor s hiring or sub contracting signature <br /> nihaa the following I conify that in the perlormancs of the work for which this permit is issued { shall employ parsons sublec' to workman s compensa- <br /> n laws of California " <br />,e appficant mug tail r all re Wired mrpecuons Complete drawing on reverse aide <br /> 1 <br /> nod Title �O 5 A Date JO M t4 4 <br /> FOR QEPARTME14'C <br /> iplicatton Accepted by Date <br /> o&t (nspectmn by 'y Final Int paction by &te <br /> s` <br />+dltlonsf Comments - <br /> plicsnt ` Return s11 Copies to SAN JOAQUIN COUNTY PUBLIC HEALTH ScRV1CLS <br /> ENVIRQNYENTAL HEALTH DIVISION PERU IT/SERVICES <br /> 445 N SAN JOAQUIN, P O UQX 2009, STUCKTON, CA 95201 <br /> INFO J.MOUNT DUE AMOU�NTT REMITTEO CASH R�ECCEEIVEO aY DATE PERMIT NO <br /> tRflr Yla Li /S �.7 �� 7 '�_ �1•� ? - '�3�7 • J �+— ^.r <br />