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APPLICATION FOR P$RYIT <br /> :� EI <br /> RRVEN" <br /> BAN JbAQUII� COMM PUBLIC BSALTH =RVICLB <br /> ENVIRONIUWAL HEALTH DIVISION <br /> SEP 0 8 1992 445 N SAN JOAQUIN, PHttfS (209)468-34$o <br /> tN%f1 ITAL HEA TH , <br /> P O BO20 STOCXTVN, CA 95201 <br /> R RVIC <br /> (Complete in Triplicate) <br /> Appliesties Is hereby oade to San Josquia County for,& permit to aonetruct and/ ittsta3l the uorlt heroin described. nis <br /> swlieatiep is Node in eas*lipfto with San Joaquin County Ordinance Mo. Sb9 a 1Et3M and tote tooter and MI(uTatione of Has <br /> JORWAs County lublie Health Bervlees. <br /> Job Address R/y lSat.>:- <br /> City Lot Sise/Aeraaae d, roy- <br /> Ow"Or's's Nems Frmc.A'A- /►tori Address 662 8e sr�+�Ols.sr.' t:�»r./rGlitot. PneMC -+Zi <br /> Contractor ! Aftgss§2140 <br /> License ffo.C•t � <br /> TYPE OF WELLIPUMP: NEW WELL:O WELL REPLACEMENT n DESTRUCTION O out or oe Well <br /> PIMP INSTALLATION O SYSTEM,REPAIR O OTHER O IJ Monitoring Velli Ilk <br /> DISTANCE TO NEAREST: SEPTIC TANK >-'&9-". SEWER LINES !A ' DISPOSAL FLD.UM• PROP. LINE _&I, <br /> , <br /> FOUNDATION gg . AGRICULTURE WELL>1i'*_ OTHER WELL 2/fie PITS/SUMPS AI- <br /> INTENDED USE TYPE OF WELL PROIId.EMAREA CONSTRUCTION SPECIFICATIONS y +� <br /> 0 Gtdust W O Open son" O Mantee DO.of Wall Excavation ie' Dia. of WON Casing <br /> X Osrtts0ic/Private N Gravel Peek O Tracy Type of Casing— ye �0 SpseMkadons <br /> • <br /> 11 PWM tel Otter n Delta Depot of(hart Sesl O=..fs0 Type of <br /> I 1 Irrigation vEV_'Apprex. Depth I I*sow" Surface Seal Installed by 02:.S <br /> Pop*Work Dona O Type of PwM &*&a H.P. State Work Done <br /> Wel ONquetbn O VM Diameter a�� Sealing Material i Dep" ,�i.rl.....':Ir ....J 4'�Lse <br /> Depth 7f Filler Material d Do rth <br /> TYPE OF 90 tC W-M : NEW,INSTALLATION I 1 REPAIR/AQDITION 1 I DESTRUCTt N 1 I (No septic system permitted it pliblic sews,is <br /> available within 200 fast.1 ''4 <br /> MwtaMlRisn will serve: Residence_ Commorcioi_ Other <br /> NurtdNt of Ntring trnia: Number of bedroom t� = � <br /> Clnrsasr of sell to a depah of 2 feta: Wear ,table depth S <br /> lEPTIC TANK. O TypelMfg Cagy No. �:�, 0 12 <br /> PKQ,.TREATMENT PLT.O Method of st IG t 4 <br /> oistatce to tteMest: Well Foundation Property Lint: tq tC <br /> LEACH NG LMOE O No. E Lsnp1S of mien Total length/taiza <br /> ALTIM 610 O Distance to norm: Wall Foundation Property Line <br /> $1E►AGE MTS I 1 DepthSas•; . Number <br /> SUMP11 LI Distance to rias met: Well Foundation Property Lim <br /> O <br /> I lW*V aas*tot i he"prepped this appkatbn and that tho;work will to dons in accordance with Son Joaquin county ordinates.sats laws, and <br /> ndso WWr Ngl/Ni M of the Sat,loaqu n Canty <br /> HOW 01111 Of Noenaa 1 agent's signature cartNtee the#allowing;"I certify that in the fwrfarm>ance of the Work for which this pwn*is issued,l shall not <br /> oniony site ppson'tn such planar as to becorns aubisat to workrrtat'scomponestion bwe of 6wornis."Contractor's hirkv or,aro-connsc*q ftitetwo <br /> a fte*8 f0111M L I "1 ON*that in the palon"anee of the work for which thispsnt*is issued,l shah employ persons subiact to workman's eontpense- <br /> den lawe of CII Owift." <br /> The apNoMK must eel for all regttired NuR!elione.Compile drawing on reverse side. L <br /> Sighed x Vzw,.A .maw»`, Thla:/.:.a.LRJ, �� � r� / s�..��ie.f ld Pas: Sty. Swli r/ <br /> a---- <br /> .90PARTMENT USE ONLY <br /> Anketion Aeesosod by Das <br /> Pk er 0rost irtipscdon by Dat Final Inspecdon by Data <br /> Additional Cerw giants: <br /> Applicant - Return all copies to: Ban Joaquin County Public Health Services <br /> noviroatsentsi Mealtlt,.Perraltl8ervices <br /> 445 H Has Joaquin, p 0 eon ,W tg, StIts, CA 95201 <br /> INFOAMOUNT.DUE AMOUNT REMITTED CA I RIECINEO BY DATE PERMn'NO. <br /> . w vas ININ.t a s A—D /�.3Z t- <br />