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tet/ <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> asse ENVIRONMENTAL HEALTH DIVISION <br /> 445 N S,'-'i JOAQUIN, PHONE (209)468-3420 <br /> P O DOX 2009, STOCETON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUM <br /> .SS (Complete in Triplicate) <br /> Appilc.tlon is herb[ t Ae to San Je.quln County for a permit to Cone truct and/or in.u11 the work heroin deacr Shed. Th1. <br /> aPPilotlop IS arde .n caolillance with Sart Joaquin County Ord]n+nee No. 549 and 1862 and the Ilulca and Regulation. of San <br /> Jaspuin Coutts, Public Health Services. <br /> _ • /. /r?/.Ti /: Gr / 1 to" Sl te/Arrenge /n�l. <br /> Jab Ad. •ee <!' - y---f-cL— <br /> Owners Lama L✓[FL n['AI /.'C:d _. Address {!":—___ __ Phone / - P <br /> e. Cobb: Ip LGYd> F_ (t.'r!'DAtl�. ss 1� Phone / <br /> TYPE 7 cLOPUMP. NEW WELL ❑ WELL REPLACEMENT Il CESTRCCTION Ll Out of Service well Ll <br /> PUMP INSTALLATION O SYSTEM REPAIR D OTHER G Honitoring 1.11 Cl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE <br /> SAO FOUNDAT!ON AGRICULTURE WELL —� OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLE AREA CGNST CTION SPECIFICATIONS <br /> O 0duatn+l O Opert SO"Ant ❑Manteca Di 1 Wall Excavatmn Du.of WON Colin <br /> f I Doman¢/Pnvate Cl Grovel Pack ❑T'.cy vpe of f-anrq, Specifications \ <br /> _ I'I PnbliC Il Dltwr Il D.lu / mol Grow Seal Type o1 Grout_ <br /> 1 Irrryjsuon _APMox.Depth I I E,ajartn Su Seal Installed by <br /> Repsi,Work Done U Type of P.n.p 11 H . _ State LVork Dons _ <br /> Well Destruction LJ WON Drorman r � u'taling Material a tey\h <br /> Depth fillies,Material 1 Depth <br /> TVTV VE OF SEPTIC WORK' NEW INSTALLATION 1 I REPAIR/AOD1T10 DESTRUCTION 11 1Na sephc synem (ASIA d if M�pl¢pwar is <br /> avmlab!a within 200 wt.l � (\ <br /> N.mithe of wdN g.,. Residence Z Colnmerclel_ Umar <br /> Number of living unite:_.L NumDsr al Mdroome�_ JT'IRAV�J`t <br /> _ Character of SON Io a depth of 3 teesl-a�-�f7�4ti'n Y 0 1 y [-nA rv+ Was.,t+h4 depth <br /> SEPTIC TANK O Type/Mfg CAp&CdY-ZjLC Na.Comp+rt+nnts `'- <br /> PKG. TREATMENT PLT.Ll fdathH of Disposal <br /> Cia to r.O to,Maraet Well-:5 'I_Fi amiAbon PropsnY One ti'[' <br /> LEACHING LINE L Na.6 Length of line. 4 -/ n Total bngtnhits_ <br /> FILTER BED _ CI Distance to.,creat. Well SCI'[ Foundation 0 S' Propels,Line S <br /> '. SEgRAGE PITS le Depth a-C//qf Ot Sim 1 /r%e t z, Number?- _ <br /> F StIMPS 01�Diatarms U are <br /> nest Foundationr.eP,---W _ _� Foundetn—iC PrnI <br /> • DISPOSAL PONDS D <br /> I Muhl gm'y'he,I have Map+rW this application and that the work will be done in accordance with San Joaquin county ordinances.slits laws. and <br /> rules and togilatmru of the San Joequrn County <br /> _ Noma Duna,Ch Ii...W ag.nCs signal.,*cend..the follawmg:'I comity that In Inc penorman"of the work lot which this perms is asasd•I shall nor <br /> .raped,any pn.on in Such menlar AF to become eubMct Io workmen's cumpan9eun Mwi of California-Conuoycloi s being or fut,con"AcUng u0naw'. <br /> Caddie.the following: 'I ldut,!hot My the ped.Irmsnc.of IM well,Or which Ih.a panni R Raued.I.hall empoy POISON.subpcl IO worknun'e companM <br /> rich lowe of cmlornle•• <br /> The app4c+nt nimt CAN toy YI rOcuryAd inapactioru.C/ompete dr+wmg on reveres nae. <br /> See <br /> �/ ./ -". 11!(-r9� Title: // �. is,-°._�• <br /> --// FOR DEPARTMENT USE ONkY <br /> wpplknion Attepud by/jam .V' ' f'P�.J rr ASN Dol _ '"-', AmPOP <br /> /�• /C y q <br /> Pat or Grout I,MpeCtion by DSU Foul Inspenbd Cy / Dau_ <br /> fldditbnel Com:rrante: - <br /> Applicant - Return n11. copies to: Sao Jd.guln Cnunly Public Health Scrrlc.rr <br /> Envlrnruiental Health Permit/Sorytien <br /> INANS 445 N San Joaquin, P p flux 2009. Stkn. CA 95201 <br /> FEE AMOUNT DUE_ AMOUNT REMITTED C�S1r PECEIVEL F, DATE PERMIT NO. <br /> INFD <br /> 1. �[ <br /> OR is Ni toes <br /> 6 .r. ,Sul �/�!'[' //�. (tP 3117 A!3 I `% :• / 9'/-3 C.k• <br /> L <br />