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APPLICATION FOR
<br /> PERMIT
<br /> &tV�P00-"G HEALTH SERVICES
<br /> SAN jOAQuIN Co
<br /> ENVIRONMENTAL HEALTH-DIVISION
<br /> 1601 E. HAzELT04-AV.E_ ' Pld&k (209)468-3420
<br /> P 0 BOX -2009',lOS.T6C.KT;ON,,-')1-4CI&' :Y6201;')(7 �t�-' OlO 'F
<br /> -roiPn9rr.Jb p � to f3qlifioc-
<br /> j i,,,)1/1 tj ri,s nI L ,yhc)qolq ivi
<br /> (Complete in Triplicate)
<br /> 1 fi, ��d 4in ,1.
<br /> Applicatioiniihertbyii�e.toSiLu-j6�quin,CoUnf, f6?''ii,'�'�'idit,to onBtr v6rk'h6relind6scrib6d. -This
<br /> P
<br /> application is made 'San
<br /> j L td..I
<br /> Joaquin County Public Health 6ery srif no '19!3t 0 r to, ifllibj��, Pifltj�w 81,kiw 19d;u 10
<br /> Vity Size/Acreage'
<br /> .)It anj;,;!�2
<br /> C4 P i�!
<br /> &
<br /> Job Address
<br /> Owner's Pd
<br /> '. az-, Iliv3rAddresses' Phone
<br /> N `Ph-one-
<br /> Contractordr�ss lii5i�i urew 64,
<br /> TY-OPE OF WELL/PUMP:, _Ii/__ NEWW L"0 - WELL AEPLAC;P4&N.T�C__- DESTR,UCTI
<br /> oni
<br /> Service Well
<br /> PUMP INSTAL -- i Sys I REPAIR,10 i OTHER mri 13
<br /> -7
<br /> DISTANCE TO NEAR7EST'-_UPTICTANk -[iF4E ROP7VINE_
<br /> -.FOUNDATION- AGRICU RF�W.ELL .OTHEF(WELL,.PITSISUMPS
<br /> CONSTRUCTION §PE
<br /> INTENDED USE !TYPE OF WELL PRO EM �EA C C61CATIO�S
<br /> r] Industrial Dja[ of
<br /> CJ Open Bottom I M eco Well Excal ation i Dia! of Well Casing
<br /> k
<br /> P Domestic/Privaie ---0---Gr66el--P i tion,
<br /> (:1 Other TyA, I Grout,
<br /> ['I Public Delta t Depth of Gro6t Sabi
<br /> i frigation th Easter S
<br /> I Appr x. I I E st a &�Zi ln.1.7;d
<br /> 4-4—
<br /> Repair Work Done,,=O- z_j-Ypo-of..
<br /> n �erial & Depth Well Destruction Oi Well Diameter S 1
<br /> erl ter
<br /> Depth J
<br /> TYPE OF SEPTIC WORK,-�-NEW INST;AL-L-ATiON-K-r-�-REPA4A4;ADIDITION-1-l-,'-DE-ST-RUC-74GN-�-I,r(,No-septic--syslem-Oermitted--if-piiblitc-sewer-is-
<br /> ;availa I h 2001feet.5 1
<br /> j I?
<br /> S?ry
<br /> Installation will e:,'-.-,Reiidenco-_, — be riComnie-r
<br /> !Number 6f bedroom
<br /> Character of soil to
<br /> Number of living' nits:
<br /> _T......____r! A. 4
<br /> 9 up-19,
<br /> a depth of 3 feet,
<br /> V
<br /> -A
<br /> SEPTIC'TANK �--Type11V119
<br /> AA tbod.?f_Djs salty I
<br /> PKG. TREATMENT
<br /> 0 ndatwon no
<br /> Distance to nearest': I[. -p
<br /> r-L
<br /> LEACHING.LINE-1 A . i Toffal [an h
<br /> j
<br /> FILTER BED 1 I Distance nearest, Well �XD Ai� tmnProperty Lina�
<br /> -C_
<br /> SEEPAGE PITS i I depth I I li;#.; NQmbeL.
<br /> SUMPS LI Distance,to near 1. ounda tion!
<br /> I!4X F* 'Property Line 1
<br /> DISPOSAL PONDS
<br /> Thereby certify that I have prepared this iapp )n and that the�worls will be dbno ik 6rd n
<br /> aict, a�c"ilh_Sa -J8aquiit-counly..drdinancesi-.statoAaws,-and
<br /> 'ri6las andregula-1-ion's of the San Joaquin Coi-inty!
<br /> 0, Home owner or lica�lnsed; ant's signature ce�tifies the following 'I certify hat in thelp erm� is issued! I_- _n(jtL
<br /> iag _eq� ari _�korkilor-whichtthis.0 .,.- - ;
<br /> Will
<br /> employ any periii6K in suith manner as to become su lect to workman's compensation 11a a lofCalifornia." Contractor's hiring of subicontracting signature
<br /> certifies the fotlowi I . ekormance,of the work -LAkall.or�oo�.-perebns-s'ubjed.t-lo.woirki
<br /> ng; 'Tc _ fiqy:whic1h 1his.p!ern�it-is�ssu r6nsicompensa
<br /> ortify that in the p
<br /> -tion laws'
<br /> _j
<br /> I -drawing-on-riaversii!o-side;
<br /> The applicanKust.call 6.0r,.qUire�$.in".ttions�--Cornp eta
<br /> &,W�41 _J
<br /> Sig1jed_X! Dale7
<br /> -L-4
<br /> _DEPARTMENTWSE_ONLV_'-
<br /> 9.
<br /> U,
<br /> 'ApplicationI
<br /> :a _�_-Aroa
<br /> Ac :Da
<br /> 1 4_ 1
<br /> DL '
<br /> Pit or Grout Inspection by D= Date
<br /> _-T
<br /> Additional Comments: _JJ. 4--
<br /> Applicant Return all c6piei to: ;Sen Joaquin County, Public Heal
<br /> 601 E. Hazelton Ave.,IP 01 Box!2009,Siockt on 95201
<br /> FEE 'AMOUNT Ou E AMOUNT REMITTED CK i RESIEI!��By NO.
<br /> INFO! CASH
<br /> EH 13-24 1R9v.I A 51 A'
<br /> EH 14:20
<br />
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