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c <br /> APPLICATION FOR PERUIT <br /> SAN JOAQUIN COUNTY :UBLIC HEALTH SERVICES <br /> rn) <br /> ENVIRCMIENTAL HEALTH DIVISION <br /> p. IiBOX 200 AVE. , TON, CAC9 44i—� <br /> 2MITR R q�H ISSUED <br /> (Complete in Triplicate) <br /> Application it hertb7 made +o Sas Jotquin County fora ` <br /> application ie no' in eoeplittr" rith BGA Joaqufa County ordlnsncenito. 549aa uo1862aand thtu �� This <br /> JaaquiA Calrlltj Public Health Benicea• INIAttIon• Cf San <br /> 6 Job Address �GtL'ft;�"�L+$V�Lz.E� t CL�� City +� (, Lot 81 to/Acrerfie <br /> Owner's Name �ddrass� lPh117 f �j �SG� <br /> ona <br /> rvF Conlratlor �Addre!! L-a � Q$`bIQ License NO,1-��Phone <br /> �� S� <br /> TYPE OF WELLlP P w IvEVY WELL UWELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Medi Ll <br /> PUMP INSTALLA110 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well <br /> DISTANCE TO NWESf: 9WIC I...... ;Z? - ^aEWErrt LiIYfS � 3�r DISPOSAL FED._Ella PROP.LINE +�f <br /> FOUNDATFt]N rti AGRICULTURE WELL LIA--OTHER WELL11_r`�,IL' PITSISUMPS �A- <br /> INTENDED USE TYPE OF WELL PROBLEMAREA COASTRUCTICH SPECIFICATIUNS <br /> [T Industrial 0 Door,Bottom a Mantsrs n <br /> pia,of Welt Ex volion Dim.of We"Casing Z <br /> 171 Domostl0plivare xprawl Pick ❑Tracy. / T�of Casing_C -frA S.ipuccil�ications 4--ozaIII2 <br /> t I IIII Prr't0crfon �Tt hw Il Oeha berth of Grout Seal ae fd L��=�+Y.�sYolr�rour r� <br /> pproi.Depth At I Eastern yurfata Seel Installed by <br /> AeFeir work Done L3, Typo of Pump _N I>r H.P. <br /> ��.� State w rk Dana <br /> 4Ya, mstnlction C. :Voll[larrtI� + r` 8eiiind 14aterial i Depth <br /> 1 r�15 r ti 1 DI Tiller Haterial A Depth <br /> TYPE OF SEP'ilC WORK: NEW INs:TALLAnoN 1 I REFAIA:AQDITION I I DESTRUCTION I 1 IIYo wplic System Permitted it public sewer is <br /> Inat'ratled vI mar's: RasidI^ Ct7rnmareltl_-,_ Othat available withfn 2W fast.) <br /> Number of Wing unite:__ :.umber of bedroom. <br /> CharactM of son to a depth of 3 feat: Water table depth <br /> SEPTIC TANK 0 TMIMI# CipacitY�_< No < <br /> PKG. TREATMENT PLT.0 . CompartMar'hod of ments <br /> Dlsynce io nearest: Wen Foundation Property Line <br /> LEACHING LINE Ll 'No.A Lehgth of Ines Total length/alae <br /> FILTER BED 0 Distance to nta:est: Well Foundation f1coeny Line <br /> SEEPAGE PITS 11 bapth Size Numrar <br /> SUMPS ll f}h;txrce to nearest: wadi Foundation_ Props.sy Line t <br /> DISPOSAL PONoS Q , <br /> I herebyrwd r@gufalktne of the gen Jaequrh Cdutt)r certify that 1 haw prepared 11Iipplkttldn tad incl the work <br /> ruka enwill be done In accordance with San Joaquin county ordinances,list@ taws,mild . <br /> Home ownlz or Ikentad agent'.L'(InAhaa c@rtlflsa the lodovving:1 certify that In the performance of the work for whlch this permit Is issued,f shall not <br /> employ any person In such mentor as Id btctlrrte tlublect to workman's compen allor,laws of California."Contractor's hVng or sub•conrtacting signature <br /> cordo@.the fn ct":1 eerdfy that In the peHonnance of the work for which thio <br /> rlon Tawe of Celtftx I#.'r parrnit Is Issued,t.hall employ persons Yub0cr to workman's tampons. <br /> The a 1 III call for AN r ired 6 <br /> ' -.- .� � •t_ion!•Cotne(*of winppn rrv@ras side, <br /> Signori ��ff ��C NTitle: Dais: z <br /> �� � lrifttrf FOR 1)E MR NLY <br /> Application Accepted by Data <br /> =�L Arta. �C <br /> Pit or(flow Impection by Data Fktallnspactlen by_ <br /> Date <br /> AddhkwW Comments; <br /> AlvIleant - Ratu" 41.1 eopi@1 tot BLo Joaquin County Public$eslth <br /> Berricee. Faviroimontal Beaith Petitit/Slrvice.� <br /> 1601 It. f zolton Ave.. P o F.aa 2009. Stockton. CA 95201 <br /> FEE y AMOUNT but AMOUNT REWITEb CASK <br /> WFO P.ECEfuFO eY 1 DATE/y� PER:NIT'Nb. <br /> .FM 1)7s(NEV.i/mele. <br /> tN:}•x _ <br />