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'E <br />-'roe APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI <br /> ENVIRONMENTAL HEALTH DIVISION AID <br /> 445 N SAN JOAQUIN, PHONE(209)469-3420"E FF <br /> P 0 BOX 388,STOCKTON,CA 95201-0388 I. <br /> r , ;. 1' ', <br /> PERMIT FIRES 1 YEAR FROM' D TE <br /> (Complete -in :•Triplicate)., rt <br /> y. � <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.This application is made in compliance with San <br /> Joaquin County Development Title Section 9-1110.3 and Section 9-i 115.3 and tht Rules and Regulations of San Joaquin County Public Health Services. 'rt <br /> 66y of Ji. R i; <br /> i Job Addresstl&lEot Size/Acreage <br /> �� I� <br /> Owner's Nam ddress Phone <br /> I <br /> Contactor <br /> Address `-'57- k Zv5 D Icense Nb. - / hone MO. �dZ ' <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT s iDESTRUCTION Cl Dui of Service Well Ci <br /> PUMP INSTALLATION CI SYSTEM REPAIR C) p OTHER O Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IDISPOSAL FLD. PROP. LINE <br />';, .__.__��_._ [SUAtOA7.tflAl. _. AGR►GLiLTLtpF wet-t-- -----+-nT►+Ef1 1lELL _.-_PtTSISUMFS j <br /> :i ii - <br /> SE NATIONAL <br /> TERRASEARCH, INC, <br /> SASAN JOW,A t15 13 NK 13668 <br /> I <br /> 1580 NORTH FOURTH STREET 90-392111211 <br /> SAN.DOSE,CALIFORNIA 95112 <br /> (408)453-1180 <br /> tCHECK'NO. CHE K DATE VENDOR NO. I <br /> F <br /> PAY <br /> ,. 10029' <br /> CHECK AMOUNT <br /> 79, <br /> Ta THE <br /> °n° ROF: /Y/' /\/}} //J�� //f��J TERRASEARCHINC. <br /> } AU HORIZEG MGNATURE <br /> M1 <br /> 00 136680 41211392164 0 1 1 2906611" 10 <br /> I <br /> r i <br /> i SUMPS Ll Distance to nearest: Well Foundation'_ `Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will ba done in eccordanca with San Joaquin county ordinances, state laws, and. <br /> rules and regulations of the San Joaquin County 1 i . t - + : '�h•�� .e ' ' <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner ai to become subject to workmen's compensation laws of Califoinia." Contractor's hiring or sub contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit.is isivad, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> I The applicant m all for all r pections. Complete drawing on reverse side. i F <br /> Signed X Title: f # Date: <br /> ,��J�FORRTMENT USE ONLY <br /> +� <br /> Application Accepted by Date: i 9�Area <br /> ix r <br /> PIs or Grout Inspection by Date Final Inspection by ji Dat <br /> Additional Comments: ql:-iaN�f/,'/ <br /> Applicant - Return all copies to: San Joaquiri County Public Health ervicesm { 1' <br /> Environmental Health Permit/Services <br /> 445 N.San Joaquin,P.O.Box 388,Stockton,f�CA 95201-0388 <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED 9Y,I t i DATE PERFAWND. M <br /> INFO] ///� �/ ry CASH u 3 <br /> En 13-21{REv.ries cwf Yom / .... ' '�� / +p�, � w �`,��`y �D / r Z <br />