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APPLICATION FOR P:.'.n`rIT �r SAN JOAQUIN COUNTY P LIC IiRpoll'If SERVICES t° ENVltgp sNTAL A$ALT11 DIVISION P O Box 2009, STOCKTON, CA 35202 (209) 468-3447 (Complete in Triplicate) lAPPllcetioo 1@ hereby sssde,to Sea Jca4uin CountyPorten to for ■ Porto Construct !-stall the!-stathe wort herein daacril Shia• 11"llcatloo 10 M40 in c�tllance vlth San Joaquin County Ordinance No. 544 and 1862 AM the BuIN a"Avaqu tlea';et<.Baa Joequla County Public Health services. �/ f �+ Job Address . 19Q5 Ili. I��oay�i�f{7 AL _. Ci, Lot$lse,Ae'..,� .�'h• e t ti" : Owrw's Name.-.. EA -,. SITI)TE Add,.. ISD. X 2GY 9 Phone t r SMZIRat �� EXP. 1 - zs75 �11Y�`rt� Sr.CDnlratltx I Address Lice TYPE ft—ft TYPE F WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION-❑Out of.EerricP-Ye11K ' s_ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER B DISTANCE TO NEAREST: S.PTIC TANK -ZGb! _ SEWER LINES I�r , DISPOSAL FLD.— PROP.i,INIE i FOUNDATIAH _/= _ AGRICULTURE WELL �€ OTHER .yfLt PITSISLMPS _ INTENDED USE TVPE OF W_E_li. PPJ$LfMAREA CONSTRUCTION S_P_F_CI_F_IC_A_T.ii0N j Ci Industrial ❑Open 3ottnm 7 Maniacs Dia. 0114£-caval on Dia:of U DrlrresticlPril air ❑Grl%*Pock 11 Tracy Type of SpecifiCattOata�._...�� IJ Publk IZ 011ier (}Dena OID+h of Growl Seal T of GrorN'-kW CJ Irrgation M Approe,Depth ❑Eastern Surface Said Installed by Z'�' ✓_�"w° "I^'`0 ,a ,: _�_ Repair Wort Done ❑ .'-Typo of Pump H.P. Sure Work Dau' ' Well Destruction 4 'WON Dionaw Sealing Iraterial i DerthOf - t?aC'Ih Tiller Material E Depth :.. s �+M.;� r'� I TYPE OF SEPTIC WORK: NEW INSTALLATION Ei . REPAIRrAODIT10N❑ DESTRUCTIONDo,"Ittio system perrwtted rt ptd*g soast la within 20Q Silt.) P . r InstANstien will Irby-: RMidencs Commartlai_ 'bttiar r i 1 i fJulnbar Or 1'+ittq trrthl: Number Of bedrooms t ' '� t u 4 rvl,3F�A�•.=a+ F ti 1:hwaatw of will to■depth of 3 feet: a. watts IabM dpth rr , SEPTIC.TANK'.- Q Type/Mfp �':NO Con N►ta # � tl# F n r PKG.TREATMENT PLT.Cl e1�i_ r' Msthad of Dkppa '. IF Diaurtce to Merest: Well FoundQ` aa�yy LStte rs y 'S' "'r--I�l LEACHING LINE ❑ No.i Length of line- g FILTER SED ❑ Distance to nearest: W.R SEEPAGE MTS I I `Depth Sire Number SUMPS LI Distance to rwrat: . Weer_` Foundation Property Lina 11Wr 4F arsrosAPo+uDs ❑ �.�..�. �. "; r I,hereby certify,that 1 tev.prepared this application and that IM work will be done in accordance with San J-.'Iquin eovnryr atilr+idtw >•Isi►1Ms,ai. . 11 tyles and requtationd of the San JoMuin Count? - - -T' •� , - s _}3 HWre Owner Or kwied pant's signature comfier the fotloAmnq:"I conity that In the perlormancs of the work far wNah this pItriliit:ii 0iW'f10f ''.employ any parson M such manner so to become subject to wworknan's compen"0on laws of Celxiornis Contractoes Itis M aul>•eontracllllp',t�i�l,iMnd 'r' dollies 1M following."I esrtify that in the performance of the work for which this permil it issued I'shall employ persons tiublact to tarorsn+en e a w✓ - _ 3 pen lawn er t'�xOrRla:; - - - ', YE q, . The oppEoant must e'ayE la aM rq fired tions.Compl.I.dnwinq txt rpwer/oe�side s: ,. _' i 9 rx 3lgnad u� �� Title: illZlE7L1 L"C'D7l lit DM:1 { r,: R DEP A ENT.USE ONLY r a Application Accepted by _��1 �i.f� Data g v PN of Orout Impaction by Date Final rmpection by �. r n o r Addkk"Commonts: t v rLi ' o APP1Icsat• Return aL1 copies tot SAN JOAQUIN COURTT PUBLIC HLLLTH BnVICE9 " t Y 9NVIRWhIENTAL B"LTIf DIVISION PONIT/:9RvICE4' 5•-r�+,rF - 445 N SAN JOAQUIN, P 0 BOR 2009. BTUCKTON..CA g3901,...., til Fo AMOUNT D!!E AMOUNT REMITTED CASH gfCEIVEO ay, ; DATt; PERMIT'NO a'4j' '' - 4 1e4a t JURa'1-r 'f .'. �jb�`�.'`"`"vya�Sa.�\:;..Efi�r�% 3•q-��:j-�`ti'k1"Sw�.;.'JF Rf,N. w.�s. ,i�.... '4