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APPLICATION FOR 4'ItikY11• <br /> 'SAN .1c!AQIIIN CUUIiTY PUBLIC HI:A1,T11 SRNVICE::> <br /> I;N V I IIONMENTAL IIEALTH DIVISION <br /> A45 N SAN JOAQUIN, PHONE (209)469-3420 �- <br /> P O ROR 2009, STOCKTON, CA 95201 <br /> (complete In Trip ll,:acc! <br /> Applleatlon Is hereby rids to Ilan '-juin r•ounty or a permit to eonstrurt an,;,or install the vert enr.:r ar•-rlh..a. Tlrls <br /> sppllratloo is made in rraq,llar.re vl•h Ban Josquln County Ordlnenco Ko. $69 see 1NbJ and the Joules ani a•rvlatlrms of Mn <br /> Jeeeuln Cnunty Dublin Health narvtrns. <br /> �_.._..,.�.. 1,tv Lot 41st/A;r.wA. <br /> Job Addtaw ,. — _._.� �._ .__._�.�ry^► t <br /> Addles• s3 A" ' �. a-- - Pnnr•e ��3���3 <br /> Qwrtet's N ams er1•. t •V+-� <br /> ,/ _ Addrttl -- ------ �. — <br /> Conlisclor ~ — .. <br /> TYPE Of WELL/PUMP NES•/WELL .'1 WELL REPLACEMErv] ;' DESTRUCTION out or 4arvlra Vill (1 <br /> _ MnnitorlrK <br /> PUMP INSTAUATION SYSTEM REPAIR 0 OTHER <br /> DISTANCE ?0 NEAREST SEPTIC TANK SEWER LINES —_ DISPOSAL FLD I PN(jP INE <br /> '•7gr r)m Tzar _ AQRICULTURI Wlll __ 0E�A <br /> NTEND UE! WfI V PR08LEM AR[A CONlTRUCTIDN SPfNb <br /> InduUnp Ij�ll nnn,` (l Maniacs Ora of Wee1arVvalrn ( y�C� of� .�Casing <br /> Y'ii, I 1 Tracy Type of Ca"#) - <br /> I I PrtMK I >✓1IMr I 1 (Nile tle/Ih of Ur out sell <br /> Itw4lbn t .P. n• t,alrlh I 1 141140" gulf#"Ilaf Ihua"ed 1-v <br /> Flop"Work Dena 1 ,_Type�l a —_--- H P. _ State Work pons_ __�--- —• <br /> Wee Destruction tl WstrOumata Bea11nS laterlel E Depth <br /> Depth Filler Material i Depth or <br /> YPE OF SEPTIC WORK: NF•W INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo sap system per I1MJ rbbC usver Is <br /> / U� � Ivsrleble w11M 200 1 .1 V <br /> Inalsitatbn win sole: Residents v Commercial ! f` r\ <br /> Number of YvKep units: I Number of bedrooms V ( , <br /> Character of sole to a depth of J feel: Water table depl <br /> SEPTIC TANK Type/Mfg Capacity101D No.Canoertmartte <br /> PKG.TREAT NT FLT. —rte P Method of Dispose <br /> t!� Dlnance to nearest: Well F <br /> i W <br /> ! — <br /> LEACHING L E No. a Length of Ines _ Tnt�l sire-- <br /> FILTER 810 1 D ttanry to .wast WaR ���.. <br /> SEEPAGE Pt S 11 Depth ___ Site Numbs --- <br /> e SUMPS Distance to nearest: Wee a Foundation IQ Prnpany Line <br /> t <br /> pISPOSAL PONDS O <br /> I hereby certify that 1 hays prepared this apokcalan and that the work will be Clone in accordance with Sen Joaquin county ordinances,state laws•and <br /> runts and rs"twd of Lha San Joaawn County <br /> Hone owner or licensed agont's signature caAilos 1"10#&":"1 Certify that M the in rk psrlormencs of twofor which this perms r reseed,I shoe not , <br /> employ any parson in such manner as to become subject to work~'a compensation taws of Crttlfornas••Contreetw's twlnq or sub-contrset"M"A"ter» <br /> certlfise the foaowing:"I eenity that m the performance o1 the work for which this pMehlt ars issued.I Mint smpoy persons subject to workman's companies- <br /> tion lawn of CaBfrxnis." <br /> Xhe oppkant neat call for M»quired Inspections. CompNto draw*ng on tr4sraw side. , <br /> Title: Dole: <br /> iignsd X_ <br /> ,!/��11 OR DEPARTMENT USE ONLY <br /> 7­1 IB <br /> Application Accepted by —� � Date �' A <br /> /"or Ora t Inspection by Data Final Inspection by Date% <br /> Addhbnal Comments: <br /> Applicant - Return all corinn to: San Joaquin County Public Health Services <br /> 6nviroowental Health Pettit/Services <br /> sen N San Joaquin, P O Bos 2009. Stlrn. CA 05201 <br /> FE1 AMOUNT DtJF AMOUNT AIMITTEO H Afe to IY OAT[ rlKMIT N0 <br /> INFO <br /> . INI}„tell 1 <br /> IN 1•to — <br />