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APPLICATION <br /> SAN. JOAQUIN COUNTY PUBLIC HEALTH SERVICES . i <br /> ENVIRON EENTAL. HEALTH DIVISION #rte <br /> 44.5 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOC=, CA 95201 lig 18 1997 <br /> _DF. IT EXPIRES I YEAR FROM_DATEX�S.U�3 <br /> (Complete in be=a!2V1&1 .Triplicate) ltr <br /> Application is herebry mada.to Baa Joaquin crnmtT <br /> for a permit to construct and/or install. the varlt This <br /> application in made to cemplianee,with San Joaquin county Ord taaaea No. 549 and 1862 and the Rules and Regulations of San <br /> „orquin Countr Public Health Berri - <br /> 35z ) <br /> eL CitY rna.jt- rot Bice/Acres a <br /> Job Address � 9�/`T� <br /> Drvrw's Nams <br /> �9r►rt�Ln �tilN Address 1 �Lr+ Pr: ter C Phom 1.) ZS6. 1 <br /> ,lddress �tl�lE rfin -License Nu. /9 16-5 Phone S�-3i "7r <br /> ® <br /> Contractor �re _ <br /> TYPE OF WELLIP P: IEW WELL ❑ WELL REPLACEMENT C7 DESTRUCT10N ❑{out Ce Veil.-© <br /> NMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER <br /> ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLOPROP. LINT: -. <br /> FOlrNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIGtnous <br /> i L, Industrial ❑ Open Bottom C1Mantes, Dia. of We11 Excavation Dia.of Wall Geeing <br /> DartlaeticlPrivats C3 Gray.[ Peek ❑ Tracy Typo of Casing Specifications <br /> Cl Public Other fl Oelu Depth of Grout Seat Typo of Grout <br /> t I Irrigation ...._Approx. Depth I I Enswn Surface Scut Installed by <br /> Rapes worst Dona U Type of Pump H.P. Stals wait Oona <br /> saali.n6 rtatrrl..L t Depth <br /> Welt Destruction d Well Diamatar ober Itat:ala}. i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAiRIA00lTIQN l k DESTRUCTION(! av availaablet" "ern permitted if public slur is <br /> vritttirn 200 faat.l <br /> Installation will serve: Residence Cvnxrtertial_ Other <br /> Number of living units: Number of badtoorrtr <br /> Character of sort to ■ depth of 3 feet: Water tsbls depth <br /> nts <br /> SEPTIC TANK. ❑ TYP*imfg CapaaN &Gvdwd+of Dl osa <br /> PKG.TREATMENT PLT.❑ f,Astlhdd of D}spasat <br /> I� Dhoutni s to naerast: Wad Foundation Property Line <br /> LEACHING LINE ❑ No. &Length of fines Total Iangthlsiss <br /> FILTER BED. ❑ Disummm to nearest: Wed Foundation PropanY Lina <br /> SEEPAGE PITS [ I. Depth _ - Slsa Nurnbw <br /> SUMPS Ll Di mese to neensst: wad Foundation Aw"ty Lias <br /> DISPOSAL PONDS ❑ <br /> 1 hereby prosy that I have prepared dus application and that the work will be done in ar_cordOwN with San Joaquin county ardinancss..stats lays, and <br /> rules and regulations of the San Joaquin Couw;T <br /> Horne owner or licensed agent's skpmmra Owufws the following:"I certify that err the parfannwwa of the wont for which thea.Permit's laud,l shad not <br /> employ any parson in such manner m to becomasubpa to workman's cornpensation laws of CaWarrim."Ca tractoes hirenp or sub-contracting signature -0 <br /> cudfm the folowing:­I carudy that in the pwftm www of the work for which this Pwmk'hs issued.I.shad employ persons subjecs to rrodm%sn's compansa <br /> bort laws of"torara." <br /> Tho Opp tican t call Complete drawing an teversa-sida. <br /> S; <br /> Tina. <br /> FOR DEPARTMENT USE ONLY O� p <br /> Application Accepted by onto Aires. (� <br /> Pk or Grout Inspection by Oats Final Inspection by Date <br /> Additional rn <br /> Comenw: <br /> ® Applicant - Return all copies to: San Joaquin County Public HesItb Services <br /> Savirocmaatal Health Permit/Services <br /> 443 5 San Joaquin, P 0 Boz 1009, Stha, GA 93201 <br /> INFO AMOUNT DtfE AMWNT REMITTED CASk RECEIVED By DATE PERMIT No. Page e I3A <br /> ;w la34 ia[v.1 i w yi <br /> r �� •�//6 <br />