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a- <br /> a <br /> T <br /> �laT1EY�'- <br /> APPLICATION FOR PE10411 <br /> SAN JOAQUIN COUNTY PUBLIC UEALTH SERVICES <br /> ENVIRONMENTAL HEALTU DIVISION <br /> 1601 E. RAZELTON AVE: , PRONE (209)966-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR-kROY PATE ItiUJM <br /> (Complete in Triplicat-2) <br /> Application Ss hereby aside to San Joaquin County for a per,ait to construct n - 'retell the - <br /> application is mile /n compliance with San Joaquin County Ordinance ho. 5:.'- .,du1662 and the 9u1e. ani <br /> Joaquin County <br /> -` CouttyFlfillcH Altth B v3 <br /> Job AddresaJYGlcee. <br /> LSl se/Ae re ,,. <br /> `< p, <br /> Owner',Name A)L.1'/ML.L>I E l 14 A A <br /> Add, cs ,,./ P"' <br /> r' f Conl'ac Addtess AJ 6 7 L- I(11 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WLLL REPLACEMENT - <br /> bSa - _ - <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> 3 <br /> !, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _— CISPOSAL fLD. PRn' ... <br /> -Yi FOUNDATION ___ AGnICL,LTURE WELL _ _ OTHER WELL PITS a:_^ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑IMuerlel ❑Open Bolcom ❑Mang" Dm.of Wen 6uvaunn __ D'u. of <br /> a r EI DMmsIK/Privet ❑GOvN Pnck ❑ Tracy TYDo of Cssmy Speuu..- —, <br /> I'I P'"Ic fl OtMr 11 Dells DePm of Grnut Seel ____ TMP. -- <br /> �y`yn I I Inigetbn _ADMae. Depth I I Eastern SuAa<s Gnul Invalmd ny. _ _ -.- ----- -- <br /> Realr Work DPM Ll Type of Pump _ H.P. 5 al®Wo(x Done <br /> Wale Destruction ❑ Well Diameter Sealing itaterlal 6 PeT•f. <br /> OePth Iler slettr3al L Deptt _ <br /> f <br /> TYPE OF SEPTIC WORN: NEW INSTALLATION I: REPAIRE54UITION rDas trJC ION INp settle within 2 peon . <br /> u^ � ✓ syadably within 200 I-1 <br /> 1v _ InstWtion wig wive: ResidenceCommercial_ Other <br /> ? IN. Number of Owing units:j— Number <br /> t n o <br /> Charente. Ware(table ,j <br /> ate:. <br /> SEPTIC TANK ❑ Typey Mfg A ___ Capacity--— No <br /> k z el PKG.TREATMENT PLT.❑ <br /> Distance la neere t: Well__ Foundation PronenY Line.— <br /> LEACHING LINE >< No. a Length of liner �� <br /> i FILTER BED Cl Distance to rarest: Well yyQ. Foundauon_/-l__ Pmpeny Lina <br /> SEEPAGE PITS Depth SNa <br /> SUMPS LI Dutanu m naaaf Well lm_ Foundauon Li. <br /> _ <br /> DISPOSAL PONDS ❑ <br /> .,r.YeRxt]5 i I hereby Cartily that I haw prep Ned this appautbn and mat the work will ba dorm in acct-L,, will) Sun Joeu,,i, <br /> rules and regulations of the San Joaquin County <br /> Homo avmar M licensed agents signature cenJsaa the following:"I eanify that In the Ix :,Tcn qt it,.wgrk fn hlCh T - <br /> 4 I amploy,any parson in such manrrr as to become wbiect to wo(kman's compin al on tathnn a"Conlr¢to(s h <br /> t cartiFNa the following:"1 cernty that m the padomwenca of the won,for which this pailr4i - v�ad,I tall employ persona sit,. <br /> f, tion basis of Cellomi " <br /> � _ _ The apWicent ug for ag mulreo inspectors.Compote dwwmp on rave�n/f{J/�da. .! <br /> Sipnad)L_ _ Tia:_l'. .. <br /> �' -1 FOR DEPARTMENT USE ONLY <br /> Aptitbatkw Atteptad by <br /> s .�s <br /> u� <br /> /a( or Grout IrmPsctbn by pata L-)f J7 F al <br /> `I AAddhbned Comments: <br /> a <br /> Applicant- Return an all copies to: BJoaquin County Public Health <br /> Services, Iov3ronmeota1 Health Permit/Se:rice. <br /> k� 1601 I. Bettelicm Ave., P 0 Bos 2009. Stork son, CA 95201 \( ; <br /> EfE <br /> INiO AMOUNT DUE AMOUNT REMITTEO CASH RECEn EC av_ DATE <br /> .Er i.2rnN „ <br /> - EN b <br />