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L <br /> 1. „ <br /> r APPLICATION FOR PERMIT II:& +aD0 Z0 <br /> SLV JOAQUIN COUNTY PUBLIC IIEALTII S V S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAT; JOAQUIN, PHONE (209)468 3 ��—� <br /> t f. y <br /> >P O BOK 2009, STOCKTON, CA 952 1 <br /> p IR YEAR T <br /> (Complete in Triplicate) <br /> ' APp11c•ttoo is Mreby awdgta Ban =oa0uln County for s Permit to construct and/or Install the vork lertln described. 'thin <br /> aPP11ea:3ov Is ode 1p eospllence .,ith San Joeyuin C---" Ordlnance No. 569 end 18ba and the Rules and Pe6uLtlone of Ben <br /> Joelu3n Cmruty Public Beelth Services: <v( <br /> . �'� r a / /✓�. 'Try Lot Slee/Acre <br /> 0,0. 7.. <br /> It's Ze7i Pnme <br /> «� �_ _P_ L�LZ—L+tenie No. & .0 _Pnon(rK '�lAf <br /> r. Address <br /> _ CCnlrr +v L.v ��•-��� _t � WELL REPLACEMENT fl DESTRUCTION ❑ Out of 9e—rvice Voll ❑ <br /> TYPE 'i+u NEW WE' - OTHER ❑ etpnitorIN;Well � N <br /> _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r' PROP.LINE a'r r <br /> I >Sar SEWER LINES >ra DISPOSAL FLD.__ <br /> DISTANCE TO NEAREST: SEPTIC TANK `n�, :1 <br /> FOUNDATION— AGRICULTURE WELL s OTHER WELL T :I CU ' <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T// B /\ 2 n <br /> ❑Open eonom ❑Mameca Dis.of Well 6pv.Mn u.of Wap CallingSZ4 7 <br /> Type of Casing_ Ovr Type ka01. <br /> Cl Domastk/privara ❑GraW Pact .. ❑TvecV r Type d Grove s. Gee.tyf <br /> 51,00,ei, (T Dale Depth of Grow Seal lr <br /> _ <br /> ['I PIIM¢ �• <br /> I I 1 Ipallerr �rAppr0a.D.plh 1 Easvern Surface SsN Innalled <br /> H:P. Slate Won Dons <br /> 5 $ Rse Werk Don. U TVps of P.m Ss•LEM R.tar1.1 E Meth <br /> *', 1 WayDestruction ❑ WN Olemnn )Tiler lYurlal E MPeh <br /> Depth <br /> r TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAi.1t, -TION I DESTRUCTION 1 in vnth..3W Mtrl W'I puck vMr u <br /> c1 <br /> 'V N.iY� IrotaYdon vAE tato: Residents_ Comn+erclel_ Other .... <br /> l ''/ 'Number of fivsq unitr.�_ Number of b.draoms <br /> Waver table depth <br /> • a „Charseur of sell b a depth of 3 flat: <br /> SEPTIC TANK ❑ TYW/Mf9 Caps<itV No.CornparlNcnve 0 <br /> h, I Method of D' 1N ^ <br /> t^�x PIG TREATMENT PLT:❑ P•epetN Line <br /> Distance to Mares: - Wall FourWnun <br /> a .r 9C <br /> LEACHING LINE ❑ No.E Lerylh of linea Tplel length/tate i <br /> r �✓t'«�, <br /> FILTER BED <br /> SED ❑ -Distance to"ANS Wall FoundnLinen P•opsM LN <br /> 'b5��2t rtyi ., CMN <br /> vlo Qpppqq �C` \ tt <br /> NumMr <br /> hi'k`F "'H'i SEEPAGE PITS 11 D", Sirs_— i <br /> rl'tC i. - LI .Durance to rrarsst: WN <br /> l,sFoundation PropaM Lina , �(`�" <br /> s �J' " DUMPS _ <br /> 1i uA'. 'D14POSAL PONDS ❑ ; <br /> 1 MrWy CMi1y that 1 haw prparW'hitaplilknion and tMt IM wort will De done M Kturdanca«rm San'Jopui.t rpunlY ord+Mr¢as,11111141 lews.and _ <br /> �9FYy NW ane rapulslbna of IM San Jopuln County Y <br /> 2';Ndrr OMMr p NCMw Efill tip,.....c n,Has 1M f.h. ng."I CertilV tNt In 1M p.HOrmNca el tM vrorh IOr whkh this parmil le taw nn I i" HI, !r <br /> olrr�pby a/Rr p•rpr,y,gyri,rNnMI as le baCMra subject Ip WO+FnHln 9 COmpanMlbn lawn 0I C-1dornts."COnlrKl les MwQ W Wb'CprI1rKIV1Q YQNNra <br /> 'paNfus tM Inlo+vq:"1 prtlfy the <br /> M Ur Wormarc.of the work in,.Mich this W rMt b issued.I atoll smpby par.una subject to vvorWMn'.COnv—' <br /> E v r r TM ApNkuAr,(�st tall for M rpuesd Inw>•cHon..C.,,owe dnu:rp on uverw side. <br /> D.1.: ? vI <br /> } rs•d Titb: <br /> r { ( FOR OEPARTMENT USE ONLY <br /> ` .. Dat. �- Area / <br /> + Applci Accepted by <br /> I'. - Date �: F pectbn <br /> by <br /> Dna <br /> a Grout Irlepacibn W <br /> EEOOir, Z <br /> r ,i AddilbiW Cantr«ru: <br /> xr <br /> Applicant - Return all copiee'ta: Ben Jo.Ru1n County Public Health Set, <ee <br /> r Snyir.e.e Ul Health Permit/Berrloo' <br /> {� -y M6 H 5.a Jo.quln, P 0 Box ]009, Btkn, CA 95201 <br /> t NED ass DATE -N <br /> F`� AMOl1NT DUE AMOUNT Af MiTTEO CASq PfCE .. <br /> 1 � .1N 11M taN.rr.0 <br /> 5X 3�/S7 a' <br /> .: y l O IN a l♦ <br /> 11", .. ... .. ... -.._ _ ..x.._..... <br /> E ( \ <br /> { F <br /> t f <br />