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APPLICATION FOR PERMIT Ick <br /> SAN JOAQULN COUNTY PUBLIC HEALTH SERVICE 4/ <br /> ENV'IR% TAL HEALTH DIVISION <br /> 445 N SAN 39AQUIN; PHONE (209)46$-34217 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT F R� ES 1 YEAR FROM DATE ISSUffi) <br /> (Complete in Triplicate) <br /> Application Is hereby mdt to San Joaquin County for a permit to construct and/or Install Lite work herein described. This <br /> application is rade in compliance with San Joaquin,County Ordinance No. $49 and 1862 and the Rules and Regulation* of San <br /> Joaquin County Public Cealth Services. <br /> Job Address !W190 E Fi r®m nryT _ city UCe�wt Site/Acreage <br /> Owner's Nome �;/I S f r(„/dmss Phone r <br /> �Contracta s?f�+® rS c✓P ,Address_� � !_asp../+gr Lwlnsr No,��a12�Ph-Re` <br /> TYPE OF WELL/PUMP: NEW WELL J WELL REPLACEMENT n DESTRUCTION O out of Service Well <br /> PUMP INSTALLATION.G SYSTEM REPAIR i_) OTHER O Monitoring Yell L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER UNE. _ DISPOSAL FLO. PROP.LINE <br /> FOUNOATION _AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> iNTENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 Industnat O Open Bottom' O Ptantecs Dia of Well Excavation _ Dia.of WON Casing <br /> r Domestic/Private C Gravel Pact C Tracy Type of Specifications \ <br /> i'1 Public n Omer rl Delta Depth of Grout Seat Type of Grout O <br /> I I litigation Approx.Depth I I Eastern Surfs,,*Seal Installed by o <br /> Rep&Work Done U Type of Pune _ H.P.��� State Wont Dons e <br /> WsR Ossnuction O Welf Oianeter Sealing Meterfel A Depth <br /> OOpth _ Filler Material A Depth <br /> %10F.SIPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION INo septic system permitted it public sewer isvsnable within ISN)teat.) <br /> n wwro dance_ Commercial dtnw <br /> Number of livwsg Wats: r of bedroom$_ <br /> Character of soli to a depth of 3 feet: table depth <br /> SEPTIC TANK O Type/Mfg �`' ®a apecity No.Compartments it <br /> PKG.TREATMENT PLT.O Method of Oisposal <br /> Distance to t: Wed sedation_ .. _Property Lina _ <br /> LEACHING UNE O No.i Length of Lees Total length/ <br /> FILTER SED O Distance to at: WSA Foundat a; Property Line <br /> SEEPAGE PITS ch Sire Number <br /> SUMPS LI Distance to newest: wall rwnds6on Property Lint <br /> OISPO ONDS O _ <br /> c reify that I have prepared this application and than 01m work will be done in accordance with S. Joaquin county ordinances,state lows,and <br /> nates erred regulations of the San Joaquin County <br /> Home o+srner or kentad Ogam's signature certifies tete following:*1 certify that in tel per'ormanee of the work for which this pwrrat is issued.I aw not <br /> employ stay person in such mPnnw as to become subject to workmcompensation' compensationlaws of CContractor'snia."Contractor'shiringwR <br /> hiring or tbrsnactirp aptu <br /> naro <br /> candy the following:"I certify that in the performance of the work for whicn this permit is issued.I shall employ persons subject to workman'sronVense- <br /> Son taws of CMiforrdO." <br /> The t Musl mal for an required Inspections.Compete.hawing on reverse side. <br /> ✓SigrsW ® o tN: Cdro @R+��a 4^ Date: <br /> QR DEPARTMENT USE ONLY <br /> Appikatfon Accepted by , �A, Oma _S_=_L_=Arca 0 Z <br /> PN or Grout Inspection by <br /> Date Final Inspection by batt f 9Z <br /> Additional Comments: YY <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Rsvirootaental Health Permit/Services <br /> 445 N San.Joaquin, P O Boa 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITI1EO KV RECEIVED SY DATE PERMIT'No. <br /> INFO 11 <br /> .EH 13•24 IAIV.v x U S t 0 V �•v'•"'). // — �� <br /> EM t47a <br />