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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEAL'T'H 99HVICES - <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (20901 <br /> P 0 BOX 2009, STOC%TO) , CAS �� <br /> a U <br /> (Complete in Tripl.iC V 1 �2 <br /> �i'OC�.?Iaynrj <br /> App/icatien ie borlbY wade to Sea Joaquin County for a permit to conatruot end/ � �H voxq'�b a" scribed. This <br /> MAGaypliettied is de So ecyIll"CO with SAO Joaquin County 0rd1nance Re. Sop and I$I tT y�Yt "It4da tion t or San <br /> JcrquSa Ceucty Publio Health Bet"Ices. <br /> JobAddraq -P�QQ<' <;,-7fi �gcR.C/FC✓ Cilv`,f4z ,erc,.� LotSi�se/Acrease /J <br /> Owner's Name .L';;A �� f,�/} Nrv{ ,-_ Address �% [' _ 'i min tv, �,., Phone <br /> I <br /> CenUaeler= V.�c1���,� DBre�irv!•, Address--�H'--5-�- /):YF'-Tr-�sr �,«xLicense No. >f ���l"a , Phone it <br /> ME 30 W Ll! UM : NEW WELL 0 WELL REPLACEMENT N DESTRUCTION 0 Out OF ery ce ell LT <br /> PUMP INSTALLATION 0 SYSTEM REPAIR M OTHER1lonitoring Voll 0 <br /> DISTANCE TO Ni SEPTIC TANK SEWER LINES DISPOSAL FLD.___�,,;.,� PROP. LINE ^..�.TC-r.:. y <br /> FOUNDATION AORiCULTURE WELL — OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ir <br /> 0 Industrial O Open Bottom O Manteca Dia. of pp~�,. Excavation Coshp B m <br /> 1 Domestic/Drivels 0 Or" Flick. 0 Tracy Type ol`Calarg_. Specifications— <br /> (1 <br /> — __ <br /> I'1 Ptpbk 1:1 Other it Dolts Depth o a Typo of Oroul gat ffYl I'll <br /> I I Initiation —Approx. Depth I I Easier udlu Seal Installed by <br /> Repair Work Dom U Type of Pumo H.P. _�_ State Work Done <br /> WAS Olftruetion ( Motor Sassing Material L Depth 1\ <br /> Depth Piller Naterial A Depth <br /> YPE i EP IC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I iNo septic fyNam parmltled 11 public <br /> available within Y00 teal.) <br /> Inefetlstion WIN tarty: Residence__ Commercial_ Other _ <br /> Nun-Am of" units: _ Number of bedrooms <br /> Character of sail to a dl pih of 9 feet: star <br /> Is depth <br /> SEPTIC TANK 0 TypelMlg —_ Capacity No. Comlportmints <br /> PKOl TREATMENT PLT.L7 Method 61 Disposal <br /> Dinanee td nearaai: Well Foundation Property Una . <br /> LEACHING LINE 0 Na. S Length of lines _..._ Total Iength%ol:e <br /> FILTER BED 0 Distance to merest: Wall Foundation C <br /> SEEPAGE PITS I 1 Depth Number n <br /> SUMPS to noMnl: Waal Foundation_ Property Line <br /> 8 O <br /> I hereby CortHy, ll 1 haw Paper o i ui sCountibn ono that the work will W done In accordance with San Joaquin county udinencss, sine lows, and <br /> rules and repWelbns of the Ban Joaquin County <br /> NORM owner or Ali~age0t'e Ngneturs certifies the following: "I cattily that In the performance of the work far which this permit It issued, I ehsll not <br /> NnPIM'Any Pereen In such mahnar as to become sub4at to workman's compensation[awe of Ca11IOmle."Contracto'r's hiring or sub-contracting signature <br /> WM"the 1040"! "1 eottlfy,that M the podormanca of the work for which this permit Is Issued,1 shell employ Persons subject to workmAn's Compton". <br /> tion laws of C81116 a." <br /> The took 104 foe M foQuked((Ipsclbns. Complete drawing on reverse aide. <br /> Sighed 1r 1 v ... Title: oat.: D- 13.�c� <br /> FOR DEPARTMENT USE ONLY <br /> Application At-tooted by / J Due 12-21-471 / Area �U` ! v CJ <br /> ►N at Grout Inepoetion by I r Onto FMtHmpsEtron-py Oatarw5lv <br /> ._ <br /> Additional Comments: <br /> Applicant - Return all copies to: Ban Joaquin County Public Healtb Services <br /> Environmental Health Permit/Servicea <br /> 446 N San Joaquin, P O Boa 9009, Stkb, OA 86201 <br /> FEE <br /> NPO AMOUNT DUE j AMOUNT <br /> EN1>t�lArv.met g �O S RFMI5J' RECEIVED By <br /> Q / VEDATI �f f �JP�E{R�MjIT'N0. <br /> /z'.�� <br /> tai e.at <br />