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APPLICATION FOR PERMIT
<br /> SAN JOAQUIN COikTY41WLIC HEALTH SERVICES
<br /> I ENVIRONMENTAL REALTH,DIVISION
<br /> 1603. E. HAZELTOX'AVE - PHbNE' (209)468-3420
<br /> P 0 BOX 2009),1111S%CKTON7111`. A '95201ari A)��,i� io ejq, ):d
<br /> C
<br /> L 11 CXPIR LF_R
<br /> _QM rDATE?1ISSUED
<br /> (Complete in Triplicate) 7f
<br /> Application is he_r_ebF_ma;ie'-to-9Z`
<br /> . Joaquin Cqun-ij r permit to cbzfetru&t,and/oi--,i3ysi�gli't e vork'herein deacribed.". This
<br /> application Is made in; e 1-1 .2
<br /> co"Pl"ric� with Ss�, Joaquin C6bht�y.�oriil:hiih-ce!',N-�'P-5L4f9l,,;',&',nd,�, �8�6 'and,thii Rules &ndtRegulations'6fSan
<br /> Joaquin County Public Health,'Services. 1 0 C, I_ (A
<br /> 61 -111,- :C.,u jf"I [,I"-% lel�!31 C Fl- �o
<br /> Job Address
<br /> �Cliy
<br /> I y Loi SilVA,r
<br /> 71 0 N 47- ig 6 C_
<br /> Owner's Name Z4&41"_ Address Phone
<br /> S'
<br /> Contractor �_`Aidreg License'N "Phone
<br /> TYPE OF WELL/PUM P:,.-- -----NEW.WELL.0.,
<br /> I__WELL.REP:LACEMkNT_[j-., DES AUCTIONP
<br /> iT Out of-Servi ce Well ❑
<br /> PUMP INSTALLATION 0 SYSTW REPAIR. 0 � OTHER 0 Monitoring Well
<br /> DISTANCE TO NEARESf-'_SEPTIC TAPI EWE R_Ll N E
<br /> SPOSAL:r-I:D._---PROP.- LINE
<br /> FOUNDATION -A RIC
<br /> —.OTHEA__WI_ PITS/SUMPS-
<br /> INTENDED USE TYPE' OF WELL PROBLE REA CONSTRUCTION SPECIFICATIONS
<br /> 0 Industrial 0 Open Bottom El teca, Dial. of Well Excavation! I l —j
<br /> Dia. of Well Casing
<br /> 11 Domestic/Private Gravel-Pack- sI1 --Tracy: e-of-c-asi
<br /> I') Public th Type of
<br /> er t%n Deltal De' 'Grout
<br /> pth of Grout Seal
<br /> I I irrigation ----.-zPprox epthI �.Surface Saw in tafl�d b��
<br /> Repair Work Done. --Type of'-puriip I
<br /> Statet-Work,Don
<br /> Well Destruction C), Wellterial & Depth
<br /> Diariiet6Ir Me
<br /> filler,Ma & Depth
<br /> IN
<br /> TYPE OF SEPTIC WORK NEW'INS-T-AL,L-ATIONK-"REPAfR/.ADI)I-TION.-I-I
<br /> DESTRUC-TI0N+4+INcseptic-SYSIOM-permitted if-public-s
<br /> available within 200 feet.11
<br /> Installation will serve:-..'Residencia I
<br /> -Commercial—7 01
<br /> k.4o
<br /> Number of living units: Number of bedrpor;.
<br /> Character of soil to a depth of 3 feet:
<br /> SEPTIC TANK. -Typ6/Mfl
<br /> PKG. TREATMENT PLT. 0
<br /> _..'_Method of Disposal
<br /> 0
<br /> Distance to nearest: Well Foundation ilk- Property Line 6
<br /> LEACHING LINE C1 No. Le�ngth-of lines III Notal le'n9th/size'
<br /> to.na,nearest:
<br /> Distance
<br /> .to ........
<br /> nearest:
<br /> FILTER BED P_Q
<br /> --�n - Di�stance.to ell Poundation _,Property Line
<br /> SEEPAGE PITS I I ' Depth
<br /> b-4,b6,1
<br /> SUMPS N
<br /> Distance to
<br /> L I 1-air,�siv: el �dati ni Propert
<br /> DISPOSAL PONDS - Cl party.Line
<br /> t hereby certify that I have prepared thii application
<br /> and that the work .dan
<br /> on ce*it Sin_J6aq6ih..county_ordinances,.state-Ia%�s,-and,,,_,
<br /> rules and regOations of the San Joaquin County' fy
<br /> "I if at in t j tce of the-w6rk tor��ich,this,oe�tmil-is-i,�sued,.I
<br /> n "I ceqLfy
<br /> Horne owner or licensed agent's signature certifies the fotloWi!2g I ! i -
<br /> _part
<br /> 1- an
<br /> es man's co- 7j t_'..
<br /> employ any person in such minner as to bicom 77' a i ornia." Contie E
<br /> certifies the following: "I certify that in the " -rformance!of the Wo�' ansatin 3 C If Ictor"s hiring or sub-conit�aqting.sdnature
<br /> P9 r
<br /> tion laws of California." work this permit is issuej_1 shalj.aj�ploi pe : na�ubjedt_to_workri-iI cdmpensa---1
<br /> Y. rso
<br /> I
<br /> Thar te.pu
<br /> ni
<br /> The apr!licanfto, I
<br /> st.ca; fo' require AIRSPS.btiOns, Complete-drawing on reveme-sids.----f-
<br /> Signed
<br /> Dite:,
<br /> EPARTMENIT.U.s OhfLy
<br /> Application Accepted by
<br /> -Date.
<br /> —Aire
<br /> Pit or Grout Inspection by
<br /> .-pate
<br /> 7 jnspectjon, Y_
<br /> � _!
<br /> Additional Comments; ate.
<br /> Applicant Return all copies to, San Joaquin County Public Health
<br /> t '.'Per0ii`t1S6rVi`ces -----�---'
<br /> -S��ices-i-Environmental-Real h
<br /> 601 E—Hazelton Ave..IP Q Box-2009, Stockton, ;CA :95201
<br /> FEE
<br /> AMOUNT CIUE AMOUPI REMITTED CK
<br /> NFO I
<br /> I CA: RECEIVED By 6ATE,0 0ERIIII4IT'N6.
<br /> EH 13-24 IREV,i 1 n 51
<br /> EH',4-28
<br /> fiL, —-L - J
<br /> IF
<br />
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