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APPLICATION FOR PERMIT
<br /> SAN JOAQUIN C6UN1iYr-k1%,IC HEALTH SERVICES
<br /> ENVIRONMENTAL HE_A_ LTH• DIVISION
<br /> 1601 E. HAZELTON AVE..;_ Aq`ANR' (209)468-3420
<br /> P 0 BOX 2409; STOCg ONj; CAS £9520.af'
<br /> i l'`� enclipriomib +ni,'�iC ,'f�`iL3quiq tijdl to gr ;ihiO
<br /> ERMITu X 1,RES_)1 <YEAIt rFRObd;�DATE r rS3.�7EDa€S� �u€�'siiu;�Y���+� i��r�n: sC
<br /> (Complete in Triplicate) i �4r ;r. �' sr � ;r•
<br /> i .. .,., r,.. �,. . ri An rrt'°47.r;:. •. 4';.•'7;".1 t"C1 S"yej�i=' •;c�,.>tscs;a :?r'E '9ii°EC) n;,l-�-+�-!
<br /> Application is hereby`made to $rin'Joaquiti County foY`ajgeimit'to construct aidyor�itYstail the work he"rein described: This
<br /> application is
<br /> QJ r vicez.a. 3. il i 62 i6fiithe-'lklea•�sadfRe?igut-l•
<br /> atIio}�!ris?''oCilf"S,lSan
<br /> 9)96
<br /> ris�Joaquin County Public HealthrServ . a, 71{ ,
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<br /> oe Ye rekiJab Address yl
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<br /> e 's Name
<br /> Addre
<br /> Ownrss_ Phone
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<br /> License No. ne -
<br /> TYPE OF WELL/PUMP:_.-.,;,,e,_ ,,.,...NEW.W 'L,. .; „,,w..,„WELL AEPLACEMEN7•10-, __,;_D,ESTRLICTI.ON_0 Out of Service Well -❑
<br /> PUMP.INSTALLATIO i SYSTEM REPAIRi❑ E OTHER ElMonitoring weii^ 0
<br /> DISTANCE TO NEAREST:"SEPTIC TNK
<br /> A "` SEIM1IER`LINES DISPbISA'L`FLD'.-" �PROP,.LINE'-
<br /> FOUNDATION. U,LT 1RELL
<br /> _ I AGRICIl ! _OTHERiW...ELL.. PITS/SUMPS.__.,,._.
<br /> LL
<br /> E INTENDED USE TYPE OF WE "'i.PROBLE ARE - CONSTRUCTION SPECIFICATIONS
<br /> 171 Industrial ❑ Open Bottom D Mantec Dial. of V`/ell Excavnonl__ I i Dial of Well Casing
<br /> [I Domestic/Private---- 0---Gravel-Pack = r-❑ Tra j-- -- -- 4 `e-of�,Gro�t
<br /> in - �!µM•= S cilicauons'
<br /> s .- , yp 9.-_._1.Y
<br /> ' L��� �.�-. I Seal t Type of''GI'I Public f 1 Other alta° Depth o __...a _- -4YM1l
<br /> + � � I I
<br /> i I I Irrigation - Apprort. Depth I Eastetn rface Seal Installed tWA
<br /> Repair Work Done;....[... TYPe..of-Pump;- _ , _.._�__._
<br /> Well Destruction O E Well Diameter I 3 { Sealin Mate gi `beptlr ; I i I f
<br /> _ _.. ... __...+-_.-..-,....._._.,.__... ......_._..._.._�_.....�.__._.�-.-_.•',_Fill r Mstgrid�' r�Deptri��.�.--...F—��}_.�-� cs'-._...lr_�r __F__,..��„. I
<br /> i Deplh i I is I I ,
<br /> TYPE OF-SEPTIC-WORK:--•NEW,INSTAL-L-ATION-I -;-•REPA4fi -A-DILTL01r� ,TlRtIGTiohf-} •: -septic m ermitted-if-gublic-se er�i W
<br /> I i i v fable Nin 2 ;feet.11i Installation will serve;"'flasidenne--�Cahrrtiercl'ar"' fttar �
<br /> Number of living:units: Number of bedrooms
<br /> 7 --I_ ,_--r --
<br /> Character of sail to a depth of 3 Feet; - W_a_t�eer_ta,�b_l_e dBpth'
<br /> SEPTIC-TANK �.._-_ ..0_.�_TypelMfg_.. .. �_ -_lapacity N0. CorTiparfinen�s� 7�
<br /> i _ I
<br /> PKG, TREATMENT PLT. Cl
<br /> Distance Ito nearest. Well 7 -Foundation i - - i ' ' I }
<br /> property Lrne I � I
<br /> +
<br /> LEACHING LIN_E ❑ N & Le ,h-.loi 7 'al leI gth/ izentnes '
<br /> 2 ) 1 !
<br /> FILTER BED C] Di '
<br /> stance to nearest: Well oundation ;Property Lrne I
<br /> SEEPAGE PITS" l I 'Depth SIYe _, .Nu beP. i 1 i- µf _
<br /> ,.- -- -- I
<br /> r _ {. -. - r -� -{
<br /> E �
<br /> SUMPS L I Distance to n6ar t i Well Foundation I roperty Lana 'I Y
<br /> E
<br /> DISPOSAL PONDS
<br /> _.-_.� ❑..�.____�__.r,___ _ _ _.:..��_.-,__-- .-- --.---?-- ` - ---__.T-- ._..�'-•:,,_.! i .
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<br /> I hereby certify that l have-priepardd_this application_and that the•w_orli will}be dbAt3 j} .dcc[udarjc.e. itk-.Sars_Jcfaquia_ca n[ ardmanees state-lawsran`d
<br /> n Jbaquin County!
<br /> ..Homnagr oe licensedjagem s s gnats!e-r.•ernfies the"follow
<br /> e wing:'"I certify that its therf rmanjce.of t}�e work`}or_vkhith'this perrrait.is..i i dl..I.sh f
<br /> 'all.not�-..I
<br /> certif eaehe fhj ollowing:lowing."Iccan fy that n the�pekounlancecoftthe wok for'wh chjh a pa fhit as.ia ues�,f k��hall�ri�Al t�rtg e�sanaaub eci�ob`cont acting signature 11
<br /> work co p g oir
<br /> I R. l Y P l l v�orkrti e -compensa
<br /> "tion laws of California.' ; I E 4 i
<br /> The applicant ust�all_for. ' q Ei►ed pe, tion'" Domplate-drawingi-on-revefse•si&.: ---I-
<br /> 5igned_X
<br /> i
<br /> --Date: I •--.' �._.l
<br /> QR_. AAThbEA17_USJ�.ON
<br /> Application Accepted by_ . i Dake "`' _ -.-A
<br /> Pit or Grout Inspection 6y-.�.. I ? 1_D,its i fillal.ltispecuan.i�iy, _ ?ale"
<br /> __.. I-_... 3 ' i i y
<br /> IAdditional Comments:
<br /> Applicant Return al
<br /> --
<br /> - i copies to San,Joaquin County, Pubis Health
<br /> ! € i
<br /> i I time is Eiealth i P€r tr5rrfie , --� -- I
<br /> (yam\ ��...
<br /> 1601 E. Hazelton Ave.,IP Q Box;2000, Stockton, ICA 195201 {
<br /> FEET i CK - I.
<br /> ,INF AMOUNT bUE N7 REMIrTTF CASH RE IV BY DATES I �'ERMIT"NO. � j
<br /> . EH13-24(REV.riw51 �•I� - ' I _I a.f... f--•--
<br /> EH 2b2a - -- - —�- -tG•-�—` -- — :......_ s .�..-... -- ..1._ _L-C�_a.(/.�_G- --4'(�e -- - r ---'
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