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i <br /> APPLICA'r I ON <br /> SAN JOAQUIN COUNTY: PUULIC HEALTH SERVICES <br /> RNVIRONMENTAL HEALTH DIVISION <br /> 4451N SAN JOAQU IN•', P110NE (209)468-3420 <br /> P U BOX 2009; STOCKTON, CA 95201 <br /> PER14 13: ERP I R&* 1 YEAR FROM-DATE_._153UJ <br /> (Complete in 'rripl.icate) <br /> I Ion is hereby made to San Joaquin County for a permit to construct and/or install the work herein descrtbr.d. This <br /> •t: fl Mian to made in cnegrltanee vita San Joaquin County Ordinaries No. 5ir9 and 1862 and the Rules Lad Regulation% of san <br /> _11•11n County.Publfc Health Services. <br /> , . .A rod?**o Z�L �� TVla.LKsO✓�_�o!a.A I Ciry!►1.G 1..+"x'fsN _ Lot Size/Acreage <br /> •.,�^r'r Name Tl Ste— t ✓c. 14.i�ti. Address ��7_� 3 /�r_i� �n�r tiTetttLJ�, _ Phone ?R4 -211 -45-*_ <br /> iZf.Kt�t b <br /> rr.tr for - B F Addre<sL..���'µt� Cl�c� Lem JA. License No. _5tt 4 2g Phone <br /> 7177: OF WELL/PUMP: NEW WELL 6f. 'WELL REPLACEMENT 171 DESTRUCTION 0 Out of service well CI <br /> PUMP INSTALLATION C1 SYSTEM REPAIR 0 OTHER ❑ 14onitorins Well <br /> '!STANCE TO NEAREST: SEPTIC TANK SEWEWLINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rl <br /> I 10rtrr911,61 - O Ogen Bottom C1 Maniacs Die. of Well Excavation v+ Ols. of Well Casing Z - <br /> ;)­,•strC/Privato CI coaval Pack 1-1 Tracy Tgpe of Casing_.__?V C Sets. Lt Q-_ Spe iflealiorta <br /> r`••hrit Ia Other I I Delle 00,01h. of (iT <br /> rrnq Seal 3r b S r _ Type of (trout T <br /> t..•ttwnnn , —� Aprvere. Depth I I Eastern Surface Saul installed by - <br /> r..rF­ Wn.k Done L7 Type of Pump � VA I+.P. RZA .---Stat*Work Done_ <br /> Oootnuciion ❑ Won Diameter Sealing Material 4 Depth - <br /> Depth Filler Material 4 Depth 44-As, ,G.xC <br /> rfr St WORK: NEW INSTALLATION i I REPAIR/At)OiTIr)N I I OESTftUCTION o septic system permitted it public sewer is <br /> available within 200 feet.) <br /> 1—tanation will save. Residence— Commercial— Other <br /> H,rmMr of awing units: Number of botdrooms (-�V <br /> r:ha,acrer of sop to a depth o feet: <br /> I owl <br /> cFPtIC TANK ❑ Type/ Capacity �. <br /> rrr, TAEATMENT PLT. ❑ <br /> Distance to near vdeu Foundation Prop <br /> t ter MING LINE C1 No. 8 Lengt 1}ne+ TDIsl pna�ro t!'u nrr,... g <br /> ril TrR BED n Dlstan o neaten: Well Foundation ENV!l�gp� UwREALIKDAWON <br /> SFarA(If PITS Depth Sire .� Number <br /> ,;I imps LI Distance to neere.at: Well Foundstion Property Line <br /> t n•rwhy certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. state lows. and <br /> r•.-•s and regulations of the San Joaquin County t <br /> rnmo owner or Ilcanaad agent's signature coMifles tfie following "I certify that in the performance of the work for which this permit Is Issued. I sholl not <br /> wmnl-y any person In Such manner as to become subject to workmen's compenaalfon laws of California."Conirectoes hit"or sub-contractino signature IrN <br /> wr„trs the follovAng:"1 eardty that In the performance of the work'for which this permit is issued, I shop employ persons subject to worlmen's eompensa <br /> tows of California." <br /> rnnlicant must cap for ad r yts -a. Complete droving on roverae side. <br /> e•A*o'f X r Title: CESZO I b L: Date: _. <br /> j FOR 4 ARTMENT USE ONLY a <br /> /l—/ <br /> Owl <br /> s.rnlicrtlon AcaHate 7�3 Area <br /> by _ •� <br /> Cit or Grout Inapectiort by Date Final Inapection by � M Date �l <br /> t�,+Innsl Comments: L <br /> APO 1.-nnt - Return all copies to:: • Stn Jongtiln County,Publ In Health Services f 1 D <br /> Envirortmontal Itealth Permtt/Services 1 <br /> 445 N Ran .Inkqutn.:iP O now 2009, 8tknr CA 9590150 <br /> • INFO AMOUNT DUE AMOUNT RTEp FMITCK H RECEIV BY DATE PERMIT'NO. <br /> f <br /> .4 0 <br />