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<_ Alehouse, <br /> APPLICATION <br /> J UIrs(, OUNTY PUBLIC HEALTH SERVICES <br /> I:OXI IfthZ11VMENTAL HEALTH DIVISION <br /> A �s -(Vis",t)IJ56' SAN JOAQUIN, PHONE (209)468-3420 <br /> O stn" Q�(,},"1d-b3'�" P O BOX 2009, STOCKTON, CA 95201 <br /> tn,�ysilY FER6[IT EYyp(CQTpEeto iDATrip118cDl_T ISSUED <br /> Application la hereby aade,W son Joaquin County for a pe:alt to Construct and/or instep the wort herein desorlbed. This <br /> APPlicAtip 1e Md. 1. staph Ance with Sen Jon In County Ordt neucc No. 5+9 sad 1862 Am the Rules Axed Re,u:etlona of Sen <br /> Joie i^ County Public Health Services. <br /> Job aaanse ?447 .S'trnin spa Gey_.�Y1u1_ Lot 31te.IArreagent o� Tc£rond <br /> Own•.'sName trn(.r /IPrIPn AOn Add ass _surer Phone <br /> Cmnacle, C2a 2k McCCW Inc Address 1014 f, Chp r,tr _License No..l%/56(1 pnpna 46 -7676 <br /> TYPE OF WELL/PUMP NEW WELL D WELL REPLACEMFN'r T-W DESTRUCTION Ll Out of 3•rvlce Yell D <br /> PUMP INSTALLATIONLO SYSTEM REPAIR D b^i <br /> OTHER G stori^` Wall ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 5{1 SEWER LINES �_ DISPOSAL FLO._ PROP. LINE, <br /> FOUNDATION AGRICULTURE WELL __ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARFA CONSTRUCTION SPECIFICATIONS <br /> ❑Industrial ❑Open Bonom D Msntaca Or,.of Wen E.cavMb— — Du.of Wan I .IN 6 <br /> YKtyJumaatin./Priwta V7 Gravel Pick ❑ Tracv 7Yps of Ca png.['le(` Speufic'mar CPN LO <br /> I'I Public 1e1 y01/ 1"1 Dal, Depth of Gout Seat 100' Tvpe of G,our CV oeenf. (^J <br /> I I Ine,atth. 14,/A7111rbv Gap" If <br /> Eastam Surface Soot Installed by / i n.4 9 nn CA <br /> Repair Work Dom D Typeof!ump 51Z4 HP.— 1"-' Stara W^d Dom <br /> Well Dinnue,ion O Wall Doinue 6 Seattle,NAterlal L Depth /;f 6 <br /> Den tet 36Piller Material L Dapth 0rk car/ 1' n/ <br /> TYPE OF SEPTIC WORK: NEW INSTALLAIIDN I 1 REPAIR/AOUILON I l OL57RUCTION l IY IN.saprn system permitted N P'de Manor n <br /> {~ avatlabta within 200 f•et.l <br /> Installation will Mrn: Residence__ Commacul_ Olh. <br /> Numlur of Gvinp anile_ Nummr of Oedrmms—_ <br /> Correct.,of aoE to is chaplet of 3 fear _Water tads depth 1 <br /> SEPTIC TANK D Type/Mlp _ CINes No.Commen,rw,b <br /> PKG.TREATMENT PLT D Method of Disposal <br /> D'r--ikota Io roust Wel_. Foundatlm__ Property Lim 0 <br /> LEACHING LINE D No.A Length of lines Total Infiniti <br /> FILTER BED D Distance to not Wap Foundation Property Lim <br /> _ SEEPAGE PITS I I Depth Sin Number <br /> SUMPS Lf Distance m marMf. Wall Foundation Property Lru ' <br /> DISPOSAL PONDS D <br /> I hereby Ser ity that I haws prepared this application and that the work well be dem in accordance with San JOaduln county ore ineencn,sura lawn,and <br /> colas and repubtilem of the San Jwnuin County <br /> Hope owner or,thorned agent's signature counters tear lonowinp:"I certify that in Ire pCormance of the work for w hkh this perm.,4 issued,I tltan an, <br /> employ any Aoki in such mai as to becom subject to workmen's compensation law of Clldo me Contractors hiring he sub-canuacmg signature <br /> certifNa the Ichlwn,g:"1 c•nity m. �Aarmklxa o1 the work for which this;,arrant is i�uk/d,I YnI N ampler Igns su��d to , n's compo" <br /> W.tion Oof Cali r II 1 I p E <br /> The applielm Io r s.Complete drawing on cavern side. ,il OD l(A,y-s l0 6(pMt"+e 18 <br /> Tide: VP CPnrk lJc P.P., Inc Oata:1 E1P/ 91 <br /> F DEPARTMENT USE ONLY <br /> _ ,. <br /> *- + App:ketbn Accepted b4byo <br /> Data Aver <br /> �-f <br /> Ph P GrcAn Impedtlon DoleFinnallImpetien!w n� D 93Addhbml Conlmnta: 'T rylleant ; 1;1llSan Jwquln Coun[Y Pubilc Ilmlth 5unfce^ AOA'..Fi-- _IL' _'a levironweotel Health Pnrel L/Seryl pee IA�WW// a <br /> t 145 N San Aosquln, P O Bre 2009, Sella, C1 95201 �- <br /> it .� <br /> / <br /> FEE AMOUNT DUE AMOUNT REMITTED K,1 RECEIVE,BY DATErl PERMIT NO. ckvii�/pi .._ <br /> PN ICat <br /> !Jp 0•VD 91-J yo <br />