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APPLICATION FOR PERMIT <br /> If <br /> SAN *4QUIN COUNTY PUBLIC HEALTH S(4VICES <br /> ENVIRONMENTAL HEALTH DIVISION - <br /> 1601 E._HAZELTON AVE. , PHONEi(209)468-3420 <br /> mnnr .rn as'J,Q1 <br /> RD <br /> Application to hereby made to San � �— <br /> netall the voik herein described. This <br /> Joaquin <br /> county <br /> wade in compliance �� \ _ �h - 2 and the Rules and Regulations of San <br /> Joaquin County F'u611c Health 9erv1 'TO V/ <br /> Job Address 1153 Vanderbilt '�����= (cQ Last- X + <br /> _ Lot Size/Acreage +300 r <br /> Owner's Neme Cal-West COn CY'E cCwC Azk <br /> r zi� � Sa_Mtca.- Phone <br /> Conhaztor Cal-West fOD('1'F le No. _32,11029—Phone 823-2236 <br /> TYPE OF WELL/PUMP: NE <br /> --- t DESTRUCTION ❑/pyt of Service Nell Ll <br /> PUMP INSTA J 4 OTHERLel tering Well <br /> DISTANCE TO NEAREST: SEPTIC TAN II\-/-+`/� QCJdUATtpr) ET <br /> �L.FLD. PROP. LINE <br /> fOUNDATlO VELL PITS/SUMPS _-rtj1r & If Ir <br /> ti <br /> INTENDED USE TYPE.OF 'A Ij - PIONS <br /> n-an BotiL... - Dia. of Well Casing <br /> - Type of Casin <br /> g Specifications <br /> Type of Grout <br /> CAL WEST CONCRETE C <br /> 1153 VANOERBILT UT74NG INC..!' <br /> ' _ r-- <br /> �_--� �_ MANTECA. CA CIRCLE 208-823-2238 4 _----- 1 <br /> 111 85338 �t <br /> PAY J <br /> TO THE <br /> Ori OF r is <br /> 11 <br /> 103 <br /> �� <br /> FOH.!_/.5,3 .e.,Manitta.Iafs], - — CLARS <br /> n9pp232tin-_E•—%� a <br /> 2 i i 1 25trr j 29 I. <br /> 35SHpy I <br /> SEEPAGE PITS I I Depth - a <br /> SUMPS I_I Distance to nearest: Well — 1�� <br /> ru,...,.,.. _ <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances-state laws, and <br /> rules and regulations of the San Joaquin County II <br /> Home owner or licensed agent's signature certifies the following: 'I certify that in the I, <br /> employ an Y performance of the work for which this permit is issued, I shall not <br /> P Y y person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must callJorall required inspections. Complete drawing on reverse side. <br /> `E <br /> Signed Xl-ria: _ Branch Manager Data: JUIy 30, 1991 <br /> FOR DEPARTMENT USE ONLY �I <br /> Application Accepted by i4 <br /> Date Area <br /> Pit or Grout Inspection by Data Final Inspection,by <br /> Date <br /> Additional Comments I� <br /> Applicant - Return all COPiea to: San Joaquin County Public Health <br /> Servicers, Fnvironmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE OUNT REMITTED CK { <br /> INFO CASH RECEIVED gV DATE PERMIT NO. <br />