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APPLICATION FOR PERMIT W I r <br /> SAN JOAQUIN COUN'l'Y PUBLIC HEALTR j( <br /> ENVIRoNN-ENTAL REAL' pIVI$IO <br /> 445 N SAN JOAgUIN, PHONE (209)488 aQ 8 1992 <br /> p 0 BOX 2009, STOC%TON, CA,,Sln,9MEE` TAL HEALTH <br /> =L F {VICES <br /> ocumlTT FSFIR&8 1-_XFit1fl �_ <br /> (Complete in TripJicllto) <br /> liostien la tveratry ¢ede W Ban Joaquin County for a permit to construct and/or Snsu11 the work herein described. This <br /> Applx to hada So neeylisnce with Ban Joaquin en <br /> Coty ordlmnee Ifo. 549 and 1862 and the Rules and Regulations of Ban <br /> ygpu,o <br /> Joaquin couhty POI Bealth 5,nicss. <br /> PJO <br /> City` r ^c ri� Lot Bi se/Acreage lL S-c!' <br /> Job AdMssa <br /> Phone <br /> pwMr's Name Adchess <br /> Asc yA-i3°1> <br /> ST S2cz License No.S' 1 RG C� Phone <br /> Sor=Cj!?�'.n D�.t r_.-/HU _Address.fib.. S_r IAYf�Lr OESTRUCTfON O Out o err ci ell <br /> Conti - - - - WELL REPLACEMENT <br /> Y W LL! L'M : NEW WELL OTHER.�p abnitoring 9e11 (] <br /> PUMP INSTALLATION 0 SYSTEM REPAIR Cl �Scir- S:-prrvGS <br /> _ -_ SEWEA LINES DISPOSAL FLO. PROP. LINE <br /> OISTANCI TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS —. <br /> FOUNDATION AGRICULTURE WELL <br /> U INTENCEO USE TYPE OF_ WELL PROBLEM AREA CONSTP.UCTION SPECIFlCATHJNS Casing <br /> "`-`��'� O Mantsce Dia. of Wall Excavation <br /> C) Industrial ❑ Open Bottom Soecuicatbns -- <br /> C7 Trac Type of Casing_— TYPa f\dR�C8'11L-� <br /> %1 patwst)e/Prbrts ❑ OuvN pack y Depth o a of Orout.�...--..-.----- <br /> I'1 Polak CI Other C1 Casing-- <br /> Delta P <br /> Approx, Deplh I ! Esalar ,urllca Soul Instilled by <br /> I I Ivi _ SStateStateWork Dons .y <br /> PistilPistilWO Work Oona U Type of Pum H.P. <br /> afMIN Beeline NaNr1a1 L Depth <br /> WaX pestn,cfiwt Filler Materiar7W!mt@j <br /> Dth <br /> Qeplh.�.'.,,.....�..----- <br /> TYPt F EP )C WORK: NEW INSTALII,TION 7 1 REPAIR/ADDITION I availa =depth� <br /> Inatil4lbn will lal Rooldenoo _- Conwr lel_. Other _Number of Wing units: __ Numbdr of bedrooms <br /> cl%l torr of so to a depth of 3 feat: Cepeelty No. Compartmu+u <br /> O SEPTIC TANK. 0 Type/Mfg Method 6f Disposal ---- - <br /> N PKO. TREATMENT PLT.Ll Foundation Property Line — <br /> Distance m <br /> ance to merest: Woo <br /> Total length/size_ <br /> LEACHING LINE I No. I Length of Imes Foundetbn <br /> fILTIR SED O rett:Diatoms to naaWell <br /> Numb <br /> 11 DeNumberSEEPAGE PITS Property <br /> SUMPe to poen" WNI FovndstlOn <br /> 9 0 <br /> I harNyy,certify that 1 hava pNparad this spiolkstbn 6114 that the work will be done in accordance with Sen Joaquin county ordinances, sine taws. <br /> rulos and regulations of the Sen Joaquin CoW+tr g; „ <br /> Horns pwwHr or konsad I1Wl's signature oll the Io"owin I Unify that in the Performance of the work ler which ng f SUI)A O tlo 1 shag <br /> employ any Wilofs kr such"Al no to bseome wbpm to workman's compensation lows Of California." Contractor's hiring or wbconttectfrq ympm <br /> otrOfW lisp folow'I+W:"1 Certify that In the psrfor rinca of the work for which this permH is Issued,I she"employ Patel subject to workman's COrnpM <br /> tion lows of cawoh)w." <br /> The WOOat Call f M),redidLspe�llons. Complete des drawing on reverse side. <br /> v IVs! Title: �R�SrDen� ` -C jw�- I Dale: <br /> Sghed I Z 1 q <br /> . C <br /> FOR DEPARTMENT USE ONLY C � <br /> Data /7 .ZL VLi _ Area <br /> Applirstlon Accepted by <br /> PH or Grout Wool by <br /> Data E2L— <br /> AddhbnN Commill <br /> Applicant - Return all copies tot $oviroomentalty Joaquin oHealth Permit/8ervicseviCes <br /> 445 R San Joaquin, Y O Sox 9009, Still CA 95201 <br /> eERM) <br /> FEE Al10UHT DUE AMOUHT REMITTED CASH RECEA/CD/r DAT[, Y NO. <br /> INFO514 14 39 <br /> W i}ii IAIY1/A el <br /> 9�'=- 653 mrv� <br />