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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 443 N 3AM JOAQUIN, PHONE (209)168-3480 <br /> P O BOE 2DO9, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FEW DATE ISSUED <br /> (Complete in Triplicate) <br /> Allpliatlna in hereby ands.to baa Joaquin County ror a paralt to construct nab/or 1anta1.1 the wort bnnln described. Shia <br /> 2WIlention to made in compliance with sae Joaquin County Ordinance lo. 549 and 1662 A" the Rules sad KepilAtlase or San <br /> Joaquta Canty Public fleafilth 6ervicea. <br /> Job AddrMf _. ��/`d � � Y/, x,24101-1 � � City ^y f.�,V• ise/AcrWla <br /> Ottrar's Name � d�Qr�yLLQ�CLf�.�r�� Address '/"� /��5,� <br /> Ca,haceor J 'Aadrvs'a[e i 193.rRw din3myAlocenre Na(/(//(/✓� Phone <br /> TV" WELL! MP: -4 EW WELL ❑ WELL REPLACEMENT ll DESTRUCTION O Out of rvip Ku <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D IlDnit:orlem 11011 ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE __ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Irlduenta ❑ Ocean Bottom ❑Mantacs Oia. of Well Emcwraian 04. of Well Caeft <br /> CI Oonwi c/Private ❑ Grevel Pact ❑ Tracy Type of Ca" SpeM6ations <br /> 11 Prtlk I'I Othw CT Delta Depth of Grout Seal Type of flea <br /> I I bngaaon _ Approm. Depth I 1 Eeeewn SwIace Soo Installed by <br /> Repair Work Dons D Type of Pump H,P. State Work Derr _ <br /> Wall Ooannawn ❑ Wept Ownetar Seaham Material A Depth <br /> Depth Filler Material a Depth <br /> TYPE OF SEPTIC WORK. NEW INSTAUAT1ON I I REPAIR/ADDITION DESTRUCTION 1 I IND Ypic ayerm punned fl public wast IS <br /> / avaanbM i,rithn 206 fee1.1 r� <br /> Irletallaliari*A true:_��S/ r�r���✓ Canewcio_, Other_ \� <br /> Feu, dw of kwM <br /> Character d No te a dans of 3 feet: Water tabte depth <br /> SEPTIC TANK A- Type/Mfp CEWeiry No, ComOamrn4 <br /> PKG. TREATMENT PLT.OMethod d O"osat <br /> Distance, to nearwl: Wap��� Fwndeeion �� / Propel w Lith <br /> LEACHING UNE if--No. S Length of Erre Total length/sirs- <br /> FILTER BED ❑ DWana torn-rrea: Well Founoawn ._ Property L --_7&W ce / <br /> SEEPAGE PAS tX DOW 1 y,1 F Sire g t+ flf�sr* umhr <br /> SUMPS LI Distance to naereq: Well Foundation Properly Line <br /> DISPOSAL PONDS ❑ <br /> 1 nerob, Andy Mat 1 neve prepared thin application and that the work wet be done in Kcaderres with San Joaquin county or6nerow state laws, and <br /> r9tee and ngtrlatione of IM San Joaquin Canty <br /> Homo omw or maned eperrl'►ti nam artlllae eM tomow"V: '.I Caney Ort In the p don"eeee of the wort for which this panne 4 ieeue0, I ahall not <br /> wilploy any preps in such mane p to beco"subject to workman't Conipeneetion Wro of Caafornia."CmdrwWo bung or wPContnetirig aigneture <br /> t WWWO tee temove,*: "I anify that in tete pwlornrrin of the work to,whial thea wrmie s inuaA.I WwO ernj perserM subwa to werkman's CertlpwI", <br /> don Isws Of CaaMrNs." <br /> The appleane mint cam for as ngt{idtl_srpea6 C plata drewn8 on reywes aide. <br /> S. lX�)J TiW: Dor: l �S <br /> DEPARTMENT USt ONLY t- ) <br /> Applleabn Aetapsd W <br /> Data Ar a J <br /> P�j ter dour VrtpK14n IN Dale -Y Fred Inspeetion b tL= � <br /> AdARwrl Cwvawea: <br /> APrilcaet . keturn fill copra to: a" Joaquin County public Health Services <br /> Seeiroseetal Health Pereit/Services <br /> e46 R afire Joaquin, P O Boa 2009, stka, CA 96201 <br /> AMOUNT DUE AMOUNT REMITTED H REC[MO By DAT! P~NO. <br /> ad <br /> . eN 1101 leey.van <br /> M wI -Qawell <br />