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APPLTCATIpN FORPSRYIT <br /> SAN JOAQUIN COUNTY PUBLIC HEAL'r jig • <br /> ENVIRONMENTAL HEAIT$ DIVISI <br /> 446 N SAN JOAQUIN, PHONE (`209)488 IS42T S 1992 <br /> P O BOX 2009, STOCKTON, (55201 <br /> PMT UE1U8 I Y&a FROM <br /> ` (Complete in Triplicate) <br /> Applioattea is heraty gado to BJoaquLa County for a Perot to construct and/or inatall the work herein described. Thi. <br /> a;Pltcatiee to MAO la cegae lsanc* with Ban Joaquin County Ordinance Mo. 749 and 186E end the Rule* and ReSulAtlona of fun <br /> Jowlin County Public Health 6ervicei. <br /> Job Addraes .G)C "012 All e-l=�f-fry Citv`t.LriCK�ry ' Lot BLse/Aereate <br /> G.N')rm•N <br /> owner's No" �'�`� I� f"�'-.}P✓'-L Addte.a L}o - i� /in 1'i � r Phone UAI�. <br /> A I <br /> Cont1aela5peCc Tek.'rn Address 7F:S'c yT Y RTL-CST- 5t-gZ,KLicense No.2i 3t lZ�.,_P Phone r'IA =045. <br /> Y W LL/ UM : NEW WELL 0 WELL REPLACEMENT 171 OESTRUCT�ION O Out ot SeryIC4 Veil <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OT✓•IER)k, isonilring Will C <br /> sclo <br /> � 6c P""CLS <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWEA LINES DISPOSAL FLD. PROP. LINE __'._..L'n:e y <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - PITSISUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial O Open Bottom 0 Manisa Dia, of Waw Excavation Casing <br /> ;.1 0041*66 TPrlvete M Gravel Pack LI Tracy Type of Cauno_ Specifications <br /> I'I P143k I:1 Other fl Delta Depth o a Type of Oroul n�tC- - <br /> 1 I hrgatlon _Approa. Depth 1 I Easter urfsca Seal Installed by <br /> Repak Work Dong U Type of Pv H.P. State Work Oona <br /> WM Destruction (N Bowling Motorial a Depth <br /> Depth Filler Material L Depth <br /> TYPE F SGPtIC WORK: NEW INSTALLATION I I REPAIR/ADOITION 1 I DESTRUCTION I I INo s=depth <br /> li <br /> avWa <br /> WtN4tfon will cowl: Raofdenco— Commarctal_ Other <br /> Number of King units: _ Number of bedrooms <br /> Character of soli to a depth of S feet: <br /> SEPTIC TANK. O Type/M1p Cepecity No. ComIp��anmants <br /> PKG. TREATMENT PLT.❑ Method bf Disposal <br /> Distance to nearast: Well Foundation Property Line <br /> LEACHING UNE L1 No. & Length of Ones Total length/slat <br /> FILTER SED Q D4tance to nearest: We" Foundation <br /> SEEPAQE MTS II Depth Number <br /> SUMPS to neMee1: Wes Foundation Property Lira <br /> B O <br /> I hereby certify that I have prepared this ■ppikation eM that the work will be done In accofUnce with Sen Josqur county ordinances, State kao, on <br /> ru40 and r"Watient of ISN Son Joaquin County <br /> Harty own&or licenaW&pith's Wanstum certifies the foadwinp: "I certlly that In the performanco of the work for which this permit is issued, 1 "nc <br /> employ env person In such manner Deo to bScW4 tubloel to workman's compensNlon levee of California."Conkactoi'o hiring or sub•contraclinp tipnMtur <br /> artMds ft fokwkg: '9 cerrY that in the ptrlamanu of the work for which this permit Is Issued,i"M ORV40y potions Subject to wofkman's oompenai <br /> Mon Iasat Of coomu." <br /> The coolie tact cA i M requiredLl "�Oonz. Complete drsw)np on never"side. <br /> SloiNd ) V <br /> 7 Title: Piz e rs1pe U- l iv Data: T <br /> Y ' FOR DEPARTMENT USE ONLY -,7 (]O <br /> Applkatlon Accepted by _ Dau 12 '�/ �� Arca J <br /> i <br /> PM or Grout Iropeetion by _ Date Final Inspection by Dau <br /> Addhbnaf Comments: <br /> Applicant - Return all copies to: Btu Joaquin County Public Health Serelcee <br /> ltoviroomental Healtb Permit/Bervicee <br /> 446 M San Joaquin, P 0 Box 2009, Btku, oA 96201 <br /> IlriC AMOUNT DDE AMOUNT REMITTED CA6H RECENED W OSA re a�J �nagaiir of. <br /> IN Di/MN.tl.0 DD �� L-63; ytA M �7-•v{7i• !G. :fl l3 <br /> rw u•7a _ _ . . �_. f A <br />