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APPLICATION FOR <br /> PERMIT <br /> &tV�P00-"G HEALTH SERVICES <br /> SAN jOAQuIN Co <br /> ENVIRONMENTAL HEALTH-DIVISION <br /> 1601 E. HAzELT04-AV.E_ ' Pld&k (209)468-3420 <br /> P 0 BOX -2009',lOS.T6C.KT;ON,,-')1-4CI&' :Y6201;')(7 �t�-' OlO 'F <br /> -roiPn9rr.Jb p � to f3qlifioc- <br /> j i,,,)1/1 tj ri,s nI L ,yhc)qolq ivi <br /> (Complete in Triplicate) <br /> 1 fi, ��d 4in ,1. <br /> Applicatioiniihertbyii�e.toSiLu-j6�quin,CoUnf, f6?''ii,'�'�'idit,to onBtr v6rk'h6relind6scrib6d. -This <br /> P <br /> application is made 'San <br /> j L td..I <br /> Joaquin County Public Health 6ery srif no '19!3t 0 r to, ifllibj��, Pifltj�w 81,kiw 19d;u 10 <br /> Vity Size/Acreage' <br /> .)It anj;,;!�2 <br /> C4 P i�! <br /> & <br /> Job Address <br /> Owner's Pd <br /> '. az-, Iliv3rAddresses' Phone <br /> N `Ph-one- <br /> Contractordr�ss­ lii5i�i­ urew 64, <br /> TY-OPE OF WELL/PUMP:, _Ii/__ NEWW L"0 - WELL AEPLAC;P4&N.T�C__- DESTR,UCTI <br /> oni <br /> Service Well <br /> PUMP INSTAL -- i Sys I REPAIR,10 i OTHER mri 13 <br /> -7 <br /> DISTANCE TO NEAR7EST'-_UPTICTANk -[iF4E ROP7VINE_ <br /> -.FOUNDATION- AGRICU RF�W.ELL .OTHEF(WELL,.PITSISUMPS <br /> CONSTRUCTION §PE <br /> INTENDED USE !TYPE OF WELL PRO EM �EA C C61CATIO�S <br /> r] Industrial Dja[ of <br /> CJ Open Bottom I M eco Well Excal ation i Dia! of Well Casing <br /> k <br /> P Domestic/Privaie ---0---Gr66el--P i tion, <br /> (:1 Other TyA, I Grout, <br /> ['I Public Delta t Depth of Gro6t Sabi <br /> i frigation th Easter S <br /> I Appr x. I I E st a &�Zi ln.1.7;d <br /> 4-4— <br /> Repair Work Done,,=O- z_j-Ypo-of.. <br /> n �erial & Depth Well Destruction Oi Well Diameter S 1 <br /> erl ter <br /> Depth J <br /> TYPE OF SEPTIC WORK,-�-NEW INST;AL-L-ATiON-K-r-�-REPA4A4;ADIDITION-1-l-,'-DE-ST-RUC-74GN-�-I,r(,No-septic--syslem-Oermitted--if-piiblitc-sewer-is- <br /> ;availa I h 2001feet.5 1 <br /> j I? <br /> S?ry <br /> Installation will e:,'-.-,Reiidenco-_, — be riComnie-r <br /> !Number 6f bedroom <br /> Character of soil to <br /> Number of living' nits: <br /> _T......____r! A. 4 <br /> 9 up-19, <br /> a depth of 3 feet, <br /> V <br /> -A <br /> SEPTIC'TANK �--Type11V119 <br /> AA tbod.?f_Djs salty I <br /> PKG. TREATMENT <br /> 0 ndatwon no <br /> Distance to nearest': I[. -p <br /> r-L <br /> LEACHING.LINE-1 A . i Toffal [an h <br /> j <br /> FILTER BED 1 I Distance nearest, Well �XD Ai� tmnProperty Lina� <br /> -C_ <br /> SEEPAGE PITS i I depth I I li;#.; NQmbeL. <br /> SUMPS LI Distance,to near 1. ounda tion! <br /> I!4X F* 'Property Line 1 <br /> DISPOSAL PONDS <br /> Thereby certify that I have prepared this iapp )n and that the�worls will be dbno ik 6rd n <br /> aict, a�c"ilh_Sa -J8aquiit-counly..drdinancesi-.statoAaws,-and <br /> 'ri6las andregula-1-ion's of the San Joaquin Coi-inty! <br /> 0, Home owner or lica�lnsed; ant's signature ce�tifies the following 'I certify hat in thelp erm� is issued! I_- _n(jtL <br /> iag _eq� ari _�korkilor-whichtthis.0 .,.- - ; <br /> Will <br /> employ any periii6K in suith manner as to become su lect to workman's compensation 11a a lofCalifornia." Contractor's hiring of subicontracting signature <br /> certifies the fotlowi I . ekormance,of the work -LAkall.or�oo�.-perebns-s'ubjed.t-lo.woirki <br /> ng; 'Tc _ fiqy:whic1h 1his.p!ern�it-is�ssu r6nsicompensa­ <br /> ortify that in the p <br /> -tion laws' <br /> _j <br /> I -drawing-on-riaversii!o-side; <br /> The applicanKust.call 6.0r,.qUire�$.in".ttions�--Cornp eta <br /> &,W�41 _J <br /> Sig1jed_X! Dale7 <br /> -L-4 <br /> _DEPARTMENTWSE_ONLV_'- <br /> 9. <br /> U, <br /> 'ApplicationI <br /> :a _�_-Aroa <br /> Ac :Da <br /> 1 4_ 1 <br /> DL ' <br /> Pit or Grout Inspection by D= Date <br /> _-T <br /> Additional Comments: _JJ. 4-- <br /> Applicant Return all c6piei to: ;Sen Joaquin County, Public Heal <br /> 601 E. Hazelton Ave.,IP 01 Box!2009,­Siockt on 95201 <br /> FEE 'AMOUNT Ou E AMOUNT REMITTED CK i RESIEI!��By NO. <br /> INFO! CASH <br /> EH 13-24 1R9v.I A 51 A' <br /> EH 14:20 <br />