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FROM A 02/ 10/33 10 : 13 P . 8 <br /> sPPLICATIOH FOR PEMIT <br /> snp JOAENVIRaWME 1tTAL XFALTH ISYS°Ices FEB 1 11993 <br /> 445 N SAH JOAQUIN, PHONE (809)468-3420 <br /> P 0 sae 2009, STOCKTON, CA 95201ENVIRONOENTALHEALTH <br /> pERM1TlSERVICE5 <br /> (Complete iA Triplicate) <br /> Applioation is hsralgr Asda to fta Joaquin County for a permit to construct snd/or install the Work herein described. This <br /> � <br /> aleatit11 is aside it CCaptiaat:e With San Joaquin Cotutttr Ordinance Ifo. 5114 tad 1562 and the Rules and Regulations of San <br /> Joattuin CotmST q uld Health earvioes. <br /> Job Address 1SCO S:5-&VA l(b AA-- Cit"MWC_C'44 Lot Shee/Arrengs <br /> Owner's Nadne "-"Ll5 Address --zZ3 S.(iRA,0 Aya_, ±R4, Lk Fhons <br /> Centritterl�t- �d� ������� AddrslsS bs ��p� �S� Lleense too. Phone,r� <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT DESTRUCTION 0 Out of SerV1.04 Well <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OHERie Monitoring 1fe11 c <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWEA LINES — DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/ffiUMPIS _ <br /> INTENDED USE TYPE OF WELL PROeILCM AREA CONSTAUCTION SPECIFICATION . 10 X A� <br /> 0 Indwtnal ❑ Open bamm I01snte0s Dia. of Wall fixrovation Dla. of Well Caning <br /> it Dom"00 0 Brand Pack 0 Ttsev Typo of Casing_ Specilicstions <br /> I'I Public f 1 atter 1-1 Detta Depth of Grout Seel ,�._ Typo of afoul <br /> I I Irrigation ....Aaprox, Depth 1 1 Eastern Outlets Seal Installed by <br /> Rstpak work Doft L] Typs 9f Ptpnp H.P. $1014 work Done. <br /> WOO DwtwOon :W Wag plamstsr Sealing Nsurial 6 Depth a2 eid <br /> QW111 _ Pillar Material 4 Depth 8U-cooi r 1 . \ <br /> TYPE OF SOPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I I INo soptic s nem perrvtiged if publiC aeww is <br /> evaitatvle within 206 fast.l <br /> insialloWn vAl serve: flssidsncC .� Cotta weial - Otlpfr d <br /> Number of living unit; Number of bedroom , <br /> C1lareatar of sot to a dapsh of S feat: Water table depth <br /> $E"fC TANK. Q Type/Mfg Capacily No.Comp wants <br /> FXG. TREATMEWT PLT.C1 Method of Oirpotei i <br /> Distance to near": WOW _ Foundation _ , Property Unei <br /> LEACHING LINE Ll No. 6 L";%h of titers - total Iangth/side <br /> FILTER BED 0 Dill"Wee to nearest: WaY Foundation Property Lint <br /> SEEPAGE PITS I I Depth $i:o Number <br /> SUMPS LI Di4torm to naisrutt Wee Foundation Property Line <br /> IDISPOSAL PONDS ❑ <br /> I hereby Certify that I have ptapared this applicalkM and that the work will os dans in accordant*with San Joa*ln county ordinancee, stet*lams, and <br /> rules drtd raguietleas of the Ban Joaquin ce=tar r <br /> Hollis awrrtr or Ilcenead apartl's signsWro certifies the Wlewinp: "I Certify that in the performance of tics work fol vrhich this porrnit is issued,I ahtll not I <br /> arniftv env Psr/gn In such wwnn subject to wortnrsn's commosetion lava of California," Contracior'0 hiring or sub-49niractin9 eltlnsture <br /> i <br /> osrtlllM the foMewing:"I hat in the rmanee of the work for wlnk:h I his parrttit is iseuari,I aheH employ Or0one etrhjsCt to workman's OOrrpen4- <br /> tlote Gllfttrnla." <br /> The■ gal raqukad I COM0410 drawing on#*Warp side. { ,, <br /> 8igrtsd Title; t"Vlo o t � �" 'r- Deis: <br /> FOR DEPARTMENT USE ONLY q <br /> `A`gplisatbn ACc*ptssd 111+ Data ` Area <br /> PR or Grot11 Nlsp4atbn by Data Final Inspection by D Z-/6-13 <br /> Additlensi c«ntrs ants: `3 — <br /> Applicant - Retura all copies to: Baa JOsdt+Iin County Public Health $arvieea <br /> Snvirono,ental Health Pertsik/Services <br /> 445 N Ban Joaquin, P O Dos 2009, 6tka, CA 95301 j <br /> INFO A114"T DUE AVOUNT REMI TEDI) CASH nE""*IV 0AyXr11r PERMITNO. <br /> . tM lint tf1Ey.s i*b - Q V ��i t� 175 <br /> IN 14� <br />