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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COMTT PUBLIC HEALTH S$RVICES <br /> ENVIRON11ENTAL REALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 20090 STOC$TONr CA 95201 <br /> • <br /> PF"IT EXPIRE$ 1 Y JPAOY DATE_115, D <br /> (Complete in Triplicate) <br /> Applleatioe to harabr sande to San Joaquin County for A permit to construct and/or Install the work herein described. This <br /> application to made in cceVliance vith San Joaquin County Ordinance No. 1349 and 1862 and the Rules and Regulations of Ban <br /> Joaquin Camtr Public Wealth Setvibea. <br /> �y� �OfJ77J Ao&&C 7r_ -- City_� Lot Site/Acreage Job Address <br /> Owns►'s Noma L _ Address Phone <br /> Coolrsew Addreie License N6. Ohons JAZ <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well Ll <br /> PUMP INSTALLATION SYSTEM REPAIR Ll OTHER C) 1lonitoritta well <br /> DIStANCE TO NEAREST: 9tPTtd LANK 35t SEWEA LINES 1-0-- PiSPOSAL PLD. nC'-*Jtn PROP. LINE <br /> FOUNDAtION --AQ AGRICULTURE WELL OTHER WELL ,�.. PITS/SUMPS 199- <br /> INTENIDEO USI} TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> tT <br /> industrial Li OpeA fioHorn ❑ Msnteba Die. of Wan E:rewAtion bit. of Well Casing <br /> 1`1 DorMstie/Private KGrabel PR6k t7 Ttacy Type of Casing_- s Specifications�7�Q$-- <br /> Pilbllc 1:1 Othat n Delta Depth of Gtoul Seat I 3_ ' _ Type of Grout 2 $A Gel r <br /> I I irrigation .S fApprox. Depth I 1061610 Surfaei Sial Iristalled by <br /> Repair Werk Done Ll Type el Pumjy I3 A-sSa N.P. 7S State Work Done V4 huTcho <br /> Well Oat"I" t] We" 0lamalat Berlina Material a Depth _tom <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPMWADOITION i I DESTRUCTION t I INo septic system permitted It public sewer is <br /> available within 200 lest.) {� <br /> Inuells on wig afro: Residence CbAtiwercial T Other <br /> Nd"W M IW)ha 0610i Nuir W of bedroome <br /> Cliaracfw of int 16 a depth of 3 hat: Water table depth <br /> E 9EPVC tANK. t] Type/Mfp Capacity No. Compartment* <br /> PKG. TAEATMfNt PLT.tl Method~Mram <br /> Dletaned to"wrest: Well Poundatlon Ptopody Lina bra./FD <br />. LIr <br /> LEACHINO LINE 0 No. A Length at AMS totdl length/size <br /> FILTER 8Eb n Dillls"s to neereit: Well ' / foundation Property L�pA�N COUNTY ' <br /> RVI re <br /> SEEPA01 0111 11 060th 4 ±aI>a Nufnbar—EN jjAQNkE'N'1AL HEALTH A <br /> SUMPA LI Dili#hei to 666441: Wall Foundation Property Line �S <br /> DISPOIAL pQNn$ 43 -- - b, <br /> I hereby esttify that I h4v4 prepared thil epplleilkih find that the work will be done in sceardenee with,9en Joaquin county ordinaness, stats laws, and <br /> rules and raputatioal ref the San Joaquin Coimty <br /> Norrie owMr M Resold agent's eian4turill aartilias the fallowing: "I certify the)in the performance of the work for which this pirmll Is issued. I shell not <br /> employ arty OP161%ih Iuth rMnr*be to b6eohre subject to worknian's Compensation tiwe of California." Contractor's hiring or tub-contracting signature <br /> eitrtif i tfli folloarlho-"I oartify that in thi parforminee of the work tot*hich thil pirrnN is issued,I shill employ persons subject to workmin'a compensl- <br /> tion to"of Camtytrtta... <br /> the Grit it ealt fot all r ukod in tion&. Com aid drawing bn reva►ab aids. <br /> ipplle aq � PI 0 .. <br /> '*"SlgMd 1t- f o4 Date: •3 /d� Q3 <br /> FOR DEPARTMENT USE ONLY <br /> Appltcatioh Aeeaptod by Data /7 hl� Area <br /> Ph of OmUt Inapseflon by Data Final Inspection b Data <br /> Additional Coinrr4nte: <br /> Applicant - Return all.copion td: Un Joaquin County Aublid Health Serviceo <br /> Environmontal Health hermit/Serdices <br /> 4411 H San Jorquiti, P O Not 9000. Stkn, dA 06201 <br /> INFO AMOUNT DUE AMOUNr�T�+REMITTto K RECEIVED 8Y DATE f ERMIT NO. <br /> EM H-21Inty.I/$I It ya4 �o �ol•C'0 <br /> H}14-X <br /> % <br />