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APPLICATION FOR rERM1T <br /> '40�AN JOAQUIN COUNTY PUBLIC HEALTH S'h dICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 LOX 2009, STOCKTON. CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> l Complete in Triplicate) <br /> APVlltatloo i• hereby made to Sao JcaOulo Ctiunty for a ptrWt to construct end/or Install the vork herein deacrlbed. This <br /> Application is asnde in ct�llsnce vlth San Jaeulc County Ordinance POP. 549 and 1862 aM the hales And ReNlatlons of flan <br /> Jopulo Covaty Pulne K(eelth 6frvlces. <br /> Job Address 7 91� - C ill: C,ty t_�:1LL;l+te a /AcreARe I Lia 'X /L C✓ <br /> Owni I Nems )���'�T / ,t / Add,an /S PIteM <br /> GOnitaCla i, �� /j��Aa0Rs3 ,�J��E-1 �(. 1. 1 � jrcense No.l/.//��-��PmeM <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT r DESTRUCTION 0 Out of Servfee Well Ll <br /> PUMP INSTALLATION O SYSTEM REPAIR CI OTHER ❑ Kooltoring Kell ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP.LINE <br /> FOUNDATION AGRICULTURE WELL _OTHER WELL NTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Indust" ❑Often Bottom O montacs One of Well Eacovalon Dia.of WN Casing <br /> rl Oo.fstk/Prlvma ❑Grsvaf Pack ❑Tra.y TYM or Casvq_ Soat'kuions <br /> - 1'I Pttblk '10~ n Delta Deoth of Gfnur Seal Tva 01 Grout <br /> I I l"'mkn _.Appro..Depth 1 I Eaten Sulfate Seal Installed by <br /> Rape Work 0. LI Types of Nanp H.P. Stale Won Don_ <br /> Wal DNtrvctien O Wall Dimas Sea1tM Iletorisl A Depth <br /> Depth Plllfr Nstarlal A Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION ESTRUCTION I I INo.,I.c.,at..pefaned d <br /> a,blic Nines,as <br /> sveitabis wrthin 700 IM61 <br /> IMleaeliOrl wW serve: Reydsnes onntherctal Mr <br /> Numbs of"unkc_L- Nurnbm cal WMoome a� <br /> Chwmw of still to a depth of O IMI: Wates table depth <br /> h p SEPTIC TANK ' <br /> No.Computmmn � <br /> F PKO.TREATMENT PLT.0 Meted of Olpe" <br /> ONtsna to naa'M; Wall, FlwMnbn PropM Lim <br /> LEACHING LINE P No.S Length of Ane, Tons length/site <br /> FILTER BED ❑ O'stanca to..at; Was F."~ PnpMW LKIa <br /> SEEPAGE MTS I I Depth Sin Number ' <br /> SUMPS LI O'sun e p narMt: Wall Foundaleon Plop"Lim <br /> DISPOSAL PONOS O <br /> 1 hereby certify IMI 1 have Prepared this bpoKstbn and that the wens wr0 be don in accordance with San Joeouin county onlevanres,Male Iowa era <br /> dap and mg,'AboM of IM San Jopuin C.*urty <br /> Moms owns a Mceneed agent's alpnatun artif:.v the Iollowin8:"I artily that in the peHor.ana of the wait far.hkh Ihk Parted is rowed.I abet nes <br /> y Mnpldy alty lnnon lin adM nvmvW as to tworM wbpcl to w nrae i'OmP~ion laws of Ceifo no."Columtoes h11Nng of eYDLMNKt11g algnarJn <br /> C vanillas the foErowinp:"f artily that in the psdor.ence of the wort for which this own*Is issued,I cull employ pasting pb)wt to wonmm's oallp esi s <br /> Von Iowa of C8ufolr)a.7-' <br /> tau ens 1}e�E C onwh0 onlraga <br /> ATMENT USE ONLY / <br /> Application Accepted by u Ane S ' <br /> tra, i <br /> t ph a Ghost IMpelion by Dau Final In Dau <br /> AddMonM Corlensrru: <br /> Applicant - Return all cllptvs to: Sao Joa.01. County Publle Health Seraleea - <br /> Fovlroonntal health Pernit/Services <br /> 445 N San Joaquln, P O Boa 2009, Stan, CA 95201 <br /> FEE AMOUNT WE AMOUNT RFMITTEg CASH RECEIVED BY DAT[ PERMn'NO. <br /> Via$ INFO <br /> t <br />