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A DPL I C_'•.'r T nN <br /> SAN .,JAQUIN COUNTY PTTBLIC HEALTfi oBRVICES <br /> ENVIRONMENTAL HEALTR DIVISION <br /> MV 1 1993 445 N SAN JOAQUIN, PRONE (209)468-3420 <br /> P 0 BOX 2009, STOCgTON, CA 95201 � 1 <br /> �'nv-f P ( l <br /> EN PERMIT <br /> ENTP, ICES PERMIT EXPIRES J BAR FROM DATE ISSUED ^� <br /> PERMITISERVICES (Complete inD -N <br /> Application is hereby made to San Joaquln County for A permit to construct and/or install the vorft herein described. This <br /> application is made in compliance vith 3a: Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. � <br /> -� I1 / -JNv <br /> Joo Address JO(I {C QY%,I1,�1C, > L �A,I� rw'(f ��� rrgry Ykk-d C C Lot Size/Acreage <br /> C_ Lot <br /> I/r� <br /> Owner's Name Prl� Iv ( ,:} fr'.ar.;r�r�VAdddress 2 Irl:t1 ) J C S .� Phond\ <br /> / 7(� <br /> rConvaclor IL =I �nv� Address/J �> / ?Y�l C rd v`C� r 54- ! 7 phone' <br /> License No. `� <br /> TYPE OF WELLi PUMP• NEW WELL WELL REPLACEMENT DESTRUCTION rl Cut of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER"Sr- Mon;tor/ng Well- <br /> DISTANCE <br /> ell Cl <br /> G0, <br /> DISTANCE 70 NEAREST: SEPTIC TANK 7L' SEWER LINES � �f% DISPOSAL FLO, bA PROP. LINE 5 <br /> FOUNDATION (/i AGRICULTURE WELL t)A OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PqOBLEM AREA CONSTRUCTION SPECIFICATIONS I Irl;I v+ -,I <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Castng <br /> (, Domestic/Private C1 Gravel Pack -�3-TrScy Type of Casing_ Specifications <br /> 1'1 Public ;1 Other t7 Delta Depth of Grout Seal I,, -> Type of Grout LPr } •J <br /> ' I Irrigation _Approx. Depth Eastern Surface Saul Installed by LC Irk- 4 E <br /> Repair Work Done U Type of Pump H.P. Stasi Worts Dona _ <br /> Well Destruction ❑ Well Diameter Sealing Material Z Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIRiADDITiON i I DESTRUCTION I i (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Conuriercal _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, M Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ` <br /> LEACHING LINE Cl No. b Length of lines Total length/size <br /> FILTER 8ED C1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS LI Distance to nearesr Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature Certifies the following: "I certify that in the oartormance of the work for which this permit is issued, I shall not <br /> employ any person in such manner s to become uktteyt to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify in the perfo of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m /qfl ( all to s. Complete drawing on reverse side. 1 (>C) <br /> Signed Title: CSC E G flete; <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 5—,Z —.0 Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: 9, 3 <br /> AppllCanr, - Return all copieR to: Sen .Ieaquin County Public Health fiervlCeR . &Q 0 <br /> Snvironmental Health PPt'mlt/Servicee T <br /> 445 N Ban Joaquin, P O Boz 2009, Stkn, CA 95201 `J <br /> Ck <br /> NFO FEE AMOU T DUE AMOt REMITTED CASH RECEIVED 9Y OATE PERMIT NO. <br /> �• <br /> �� t�. A� ,,.s, �D3/771 5—/z­�3 q3 —08� <br />