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APPLICATION <br /> SAN .10AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOK 2009, STOCKTON. CA 95201 <br /> PF AZT EXpIRL "R FROY DATE ISSUED <br /> (Complete 1G Triplicate) <br /> ,W See Jwquin County for o permit to cone trust and/or lnsuli the yore hereto described. This <br /> Application Is hereby mufe <br /> syyllestlov L cede in <oegl Lnee vtth Ban Joaquin County 0"J"Ance go' 5L9 and 1862 sod the Rules avd P9NLtlona of Bae <br /> dosquly County Public Health Beryleee. <br /> S. — City_, Lot Blee/Aere+ae � <br /> Job Address T "3- <br /> phone <br /> a! AO@nes <br /> Owner's No //�7 <br /> Contract. � Adduss <br /> ((f��• �� License No. Phone <br /> TYPE OF WELLIPUMP: NEW WELL - WELL REPLACEMENT .`i DESTRUCTION Ll Dui oNpnlurill{Well <br /> ❑ <br /> SYSTEM REPAIR L, OTHFR O <br /> PUMP INSTALLATION ❑ DISPOSAL FLD.__ PROP.LINE '. <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL __— OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION$ Dia.of WON C-116" <br /> U Open Bottom 0 Maniacs Dia.of Well Excavation <br /> ❑Industrial E of Casino__ Spvcilkatlom <br /> { CI Public Pdnte Cl GnueOther Pact ❑Tracy Oe0 h Of Gout Seal Type of Grout <br /> I'I Pudk I Drber Il Delta <br /> _Aple... Depth I I Ea,uHn suit Seel Inualatl by <br /> I I brpatlon - $tau Work Dona_ 1 <br /> I.P. <br /> Repair Work Done L7 7YDe of Pump Sea11nB Ilaterlal E Depth ' <br /> Wall Destruction O W.N Diameter Filler Notarial A 1IAPth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTAILAT'ON REPAIR/ADDITION DE5TRUCTON 1 available <br /> w thin 200 f mtt, rW u <br /> Commercial_ Other <br /> Installation will NM: Residence_ A 1 "�//t� <br /> Number of Eving units:_ Number OI bedrooms�//'yE /�/n /rO T/ � '+ Weur table depth <br /> Chnacur of wit to•depth OI 71seClCKapacilt l�No.Compartmanu <br /> SEPTIC TANK 0 Type/Mfg Msihod of Diego" <br /> PKG.TREATMENT PLT.0 Foundation PrOMMY Lira <br /> pislance to ruernr. Well <br /> _ ----- <br /> Total la gth/aixe <br /> LEACHING LINE 0 No.b Length Of lines PropeM Lim <br /> FILTER PED <br /> Distance to noose Well Foundation <br /> Strs—_ Number <br /> SEEPAGE PITS II Depth Property Lim <br /> SUMPS <br /> LI Distance m psoras': Well Foundation <br /> DISPOSAL PONDS 0 <br /> I heHbY<anifY that Mve Prepared this application end that In.lvolk will be don.in-cCiurit CO with San Joaquin county Ordinances,stats WIa,and <br /> rulas and regulations of the San Joaquin CouctY signature <br /> Home owner Or lice n ed s manner is signature courlies <br /> to become subject folllo workman.compensation awe of California."the <br /> hiring ofwDcorit"ting seg II not <br /> employ mY portion dn•mance of the work for which this permit Is,iliued,I sbell emplrY parsons subject to workmen i<rmWnu <br /> certifies the following:"I comity Inst in the pe <br /> turn laws,Of California." <br /> The epplka at tall for all reqs d ins tions. 4pmplete clawing cit nveru"o. - <br /> /t/. n,0 Dau: <br /> Title: / <br /> Signal <br /> _ FOR DEPARTMENT USE ONLY n s�S <br /> Dau O-' _ Ana G'[ <br /> Application AecplM by Dau�•�� <br /> Pit or Grout Inspection by <br /> Data Final lnspectivn by <br /> Additional Comment.: — <br /> Mbllc Health son Joaquin <br /> Applicant - Return ell "OP1e. to: EnvlromiontalruntHealt b Peradt/Bervlerevlcpe <br /> 995 N Sec .roaq.l n, P Ge Box 2009, Stkn, CA 95201 <br /> K AI LVED BY DATE PEAMIT'r90. <br /> FEE AMOUNT OUE AMOJNT Pf MtTTEO [ASN <br /> . for tsI Itune Ir+H e / <br /> .v.a <br />