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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN. PHONE (209)468-3420 <br /> P O BOX 2009, STOC%TON, CA 95201 <br /> PERMIT E%PIRR.S 1 YEAR PRMI DATE ISSDED <br /> (Complete in Triplicate) <br /> A"llestlon is thereby Made to Sao Joaquin County for and/or <br /> a veva t to construct lPEI ts <br /> he vert herein deeribed. This <br /> oEPltuGiPe 1- Mande in cryilance Ytth Ran Joaquin County Drdtaance No. 549 and 1862 awl the Rules end Hedulatiom oT Sea <br /> Joaquin County Public <br /> �th alta Sersieu. <br /> Joh A,Mw -�'^ •1 }( �U . (yf EtAr , Car 4 ��L t Sire/Acrmge �C.Ifr.(�llSi _ �t <br /> Owmta N.m. CLU\{}1"t't�1Mall..tr51L Addr n /D✓r !"7�L" <br /> Contract' 1^'C H/ iSaddles,-i6.Ut7l(�b7 Pr.6r.L-r License NO: 2T 2Z& Pmhs " '`l/d� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ put of Ellice Yell <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Norileclull Yell ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL MOSLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑DEEP Sono ❑Mhnwcs Dis.of Wail Escgatipn Ow. of Was Casirp <br /> Cl DormaNGPllvss ❑ Gravel Pack ❑That, Type pf Cuirry_ Swifkadons <br /> 1'1 P,Ibpc ❑ Other Tl phot, Depth PI Grant Seal TYPE N Grout <br /> 1 Initiation _Approe. Depth I 1 Eaumv. Sud..East InalNed by <br /> Remix Wok Oche ❑ TYPE,of Pump N.P. Sot,Wok Oona_ <br /> WN Duhuetan ❑ WN Disrmter Estella, snttsrial It 0gtb <br /> DE,ph — H1Lr Ratarial E It"th <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAI ADDRIO ,DESTRUCTION ( I INo uprz svatem WsvRed d pup&sewer s <br /> sYM1abnt wilhin"tum a <br /> lmlhaMion Evia qM: RgMntce r Com .w_ Ot <br /> W hhr 1 /y <br /> Nu ubE,r hvwJ <br /> E ods:_L_ Numher of ba'Skoane - —/ <br /> Character o1 end w a mpN of i out: + >'`-'tom— Water tont tlgtn 't V <br /> SEPTIC TANK �Typill" F - ' CePEcgy T ' No. ComptROFnte <br /> MCG. TREATMENT PLT.❑ y 1 MaNpd of pisousl <br /> Dntlhnm to r1eE,M: WN_,,�Ojpe <br /> _ Foundation�L Property Lim <br /> �^ _! �✓7 <br /> LEACHING LME No. S LNISH of aims _ ' �- SJC �' Tonal NngIDloin ter 1l Iful <br /> FILTER SED ❑ D4uon to mathM: WN Fowdenon11)t _ Pep"LM <br /> SEEPAGE PITS I o Dprh _Sin Nurnher <br /> SUMPS it DntterrA w metal Wall Foentswar Prower Lim <br /> DISPOSAL PONDS O <br /> I""by MnWV that I hal wootha l this application and that the work YI be dom Is srCormnu with San Josquin County ordmncq,slaw Hors. and <br /> loss ab hQualshav N Os Son Josquin county <br /> Horrw shunts o"-Anted pant'-Mail vA-hs nnifs-Dw thllowinp:"I certify telt in aha PEdormanu of the work fo which Nis 1"I s wRNd,1 land riot <br /> ORVIDY ay pMhwl el a sch mMmr as w bacom ephlAet to W niche f G fAmpemalpn tans N CNfornit."'COatrKlote Wft or WafdlDhttwE altirwlWa <br /> Passfiq this f0lmstrIT"I cerNy Net in the PE,dormsncE,N rare work for which this pannh HE issued,I Mali enploy perhoru subjser tp averkmar"conpnq- <br /> Non Inas of Cogo ." <br /> Tim appicar. M WI I"r qukW Msgctio s. ConpNNw Whwvp en..an <br /> sow x J ela <br /> T : kr?. <br /> ? Date: `13 <br /> t FOR DEPARTMENT USE ONLY <br /> Application Assistant by Data Ahs <br /> PH Or Grad Intimation by Data FSM Impaction by Dew <br /> AddKiwlM Comment: <br /> ApPiitant - Return all copies to: She Joaquin County Public Health Services 5 QD r <br /> Nallaoaaental Health Peewit/services _ <br /> 445 R San Joaquin, P O Em 21)O9, Stko, OA 95801 <br /> FEE —Iwo AMOUNT WE AMOUNT REMITTED CASH RECEIVED EY DATE PEflMYt'NO. <br /> . <br /> an Ddt law..,... <br /> teww <br />