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APPLICATIOX, TOR PERMIT <br /> SAN ., AQUIN COUNTY "I,It; nALTR S"'110ES <br /> ExvIRONHSNTAL R.$ALTR DIVISION <br /> p 0 13O% 2009, STOCICT}N+ CA 9$201 <br /> (209) 499-3447 <br /> (Complete in Triplicate) <br /> Application to hereby made to San Joaquin County for a permit to t6notruct and/or initill the work herein described. This <br /> application is made in colWilante with San Joaquin County Ordinadca Nes. 549 and 1862 iuA the ilulea aye Regulations of Ban <br /> Joaquin County Public Health Services. <br /> -78 g a 1 vd city Trot c Lot sid!/Acrea4r! <br /> Job Address /� qg <br /> I.t n p `ppb • _ Address �� +— D + Pfronr� 7 �`� <br /> 43 <br /> Owner's Name r <br /> ll rrtt 11 9.16 <br /> Cemtraetor �t<elt Lt'"e1rlC Y,'� r' Address LICI!nst! No. $ Pfioit <br /> TYPE OF WELL/PUMP; NE ELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 binnitoiing Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES q 0 't - - DISPOSAL PLC), PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHERWELL_ PITtISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSA. <br /> n <br /> L1 Industrial 0 006M Bottom 13 Mahtics big. of Well Emcavalion Dig. of WON Caaing <br /> jYd . PVI- S cificslions , +� <br /> U Detmealkl'PNvata C7 c3rlwl PacR racy - - 'W'tv{�Ir Ise fiidrnG� �,-•�, pe <br /> 13 Otiblie 1-1Othert7 601 LIS <br /> Depth of GroUI Setif cry �+d1 + Type of Grout �H►..Tr.� <br /> ❑ Imripation 1.'2..AppfoR. Depth r] Eastern tur�iee goal Ihstellad by Cit Gie+al+ Pr4l.,04 <br /> Repair Work Done U Type of Pump H.P. - State W6&DMIll <br /> Wall Destruction ❑ Well Diameter Sealing isatorial i Depth — <br /> Depth fillet VAteeial i D6pth I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L] REPAIRrADDITION 0 DESTRUCTION CJ Wo septic system permitted if public sewer is <br /> available Within 200 leot.l <br /> Installation will arve: Residenco— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of sop to a depth or 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity Na. Compartmlfenti <br /> PKG. TREATMENT PLT.❑ { Method of Dltlpolaf <br /> Oitunce to nearett: Well ____. 1. Fdundelion--- -_— Pfopahy Line <br /> LEACHING LINE 0 No. 8 Length of liner -�c - _�_-_ -�.-Total lenoth/lir• } <br /> FILTER RED n Distance to nearest: Well Foundstlon I _ Property Lind <br /> SEEPAGE PITS 11 Depth - ____Silo Mumbet' <br /> SUMPS Lf Distance to nearest: Well + Fbunditibn _ Propetty Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prfpsioa Ibis application and that the wort will be done in accordant! with San Joaquin county ordinances, state laws, and <br /> rules and rogulationi of Ihi San J6&g4jlrf County - <br /> Home owner or licanaed agent's signature certifies the following: "I cee'tify that IH the Odriormante of the*ork for which this permit is issued. I shall not <br /> employ any parson in Sutsh minnat if to becib6ht Subject to workmen's cortibeniallon Iiwi bt Lalifotnik" Contrictbr's hiring or Sub-contracting eigneture <br /> certifies the following: "l tertlfy that In the pbriatmance df the work for which this permit i1 ideuod, I$hill employ pardons Subject to workman's compents- <br /> tion laws of Callfwnlf." <br /> The applicant If requir a ons. Complete drawing on rov Side. <br /> � f <br /> Signed X Title: Date: 7��Z9/FOR DEPARTMENT ll! ONLY L <br /> PApplication Aecipted by ._ Data ?ZTL(?' Araa' - <br /> Pit of Grout 4napoction by Date I y Pitta! nir�ecllon b' _ Data <br /> Additional Comments: <br /> SAN�CSAQum COMM;-MLIC HEALTH SERVICES <br /> *t•rnn.+ir•1R•r.N.• •Mi ...•.. •r.�f . -• •---- <br /> Applicant - Saturn all copies tot SAN JOAQUIN COUNTt PUBLIC HEALTH b - -1 A' PEM <br /> y j*rlr <br /> ENVIRONMENTAL HEALTH DivISIOH Pau �Q �(y-1" �,JL'+,�1 I <br /> 446 H SAN JOAQUIN, O so! 7069, STLXITOH, CAI 701 <br /> `I-FEENFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By m DATE PERMIT NO. <br /> • EN 13.7.[REV,I1*s1 yy 00 • 9�..� <br /> 11 11 <br />