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<br /> Rli
<br /> MAR
<br /> �W-Mw,
<br /> APPLICATIO.Y FOR PERUIT
<br /> SAH JOAQUIN r PUBLIC EEALTH SERVICE,;
<br /> �[ IE�.LTH DIVISION
<br /> SANj�� O�U Uf� 9. STOCKTON, CA 95201 1
<br /> -209) z 2 1 1991
<br /> SPECIE
<br /> �- 6R rROH I7ATri r c
<br /> AP7l.:attoc to hereby maac en s.a (Cof;plete in Triplicate}
<br /> a 49ulat'" U tu.de in C "c+qulp CCuntY fv:a
<br /> }+t JaaSula Ceusaty Public g �li er,y,with San ,T=quln Coup --A to conatrucL and/cr Inaarl lithe York herein deecribeZ, This
<br /> i ea..h 8atvlcee, Y pr--lance lip. 51,9 and r: the
<br /> Serer 1662 Rules acd Ae
<br /> Jab Addreat ' G $";" Cersr, 11 "lationa of San
<br /> City 'r-a.(r Cq .
<br /> Lot Site/Acreag
<br /> Cwne%s Nama e 8 C1tYrl T2
<br /> q`
<br /> contractor '�0��y�r peCress ` ~ggtr! Cbreye,/tj 7`.� Phana rJL4/
<br /> l:a TYFF OF YyELIIPUMv. � ?LTLLTP�q/ Lrcer.se fiQ,5 tt�C7. �/
<br /> NEW VrELi ., d WELL REPLACEMENT 0
<br /> I FUMP INSTALLATION ❑
<br /> p1STANCE TO NEAREST; S-- SYSTEM PEPAiR DESTRUCTION ❑ Out of Service bell 0
<br /> Mw---� �rrlC FANK M4
<br /> �t GS7yM1r,ZG ----�� SEWER LINES OTHER OTHER ❑ Monitoring Well
<br /> FOUNDATION 5'✓L -gGAICULTUAE`h DISPOSAL FLD. �y PROP-
<br /> i IN';LADED USE ELL a/d UNE _r/irvr
<br /> tiWd TVP[OF WELL P OTHER WELL � '*or P;TS/SUMPS NA
<br /> L7 Intlusanal -� ROBLEM AREA CONSTR
<br /> Open BottomEM-71 ..
<br /> Man— t — UCTtON SPECtFICATtONS `
<br /> U Domestic/Private D,e. of Woll Eycavatrcn- ti e
<br /> C7 Grave!Fack 0 Tracy —��� Dia, of well Casing �'y,
<br /> Public TsPe of Casing ?v C.1.7 Ofhn.
<br /> G rn,Uatron "�Deltp Dept of Grout Sea] +-$~ Specifications.,»,_�
<br /> �r/ 0rAPPrQa. Depth Eastern Type Of Grout Ai cc
<br /> Repair WorkDoneSurface Seat Installed try
<br /> Well Dae[ruct on [3 T7pe of Pump
<br /> lw H.P.
<br /> _
<br /> 0 Wall Mameler Seal: ;�— State Work Done_
<br /> �. 1Zdti•a.I�4irs�
<br /> Depth �T�IlGar ng Mattiia_ L Depth
<br /> Filler
<br /> TYPE OF SEPTIC tVOAK: NEw a Material Stepth /'}
<br /> NSTALL.ATfJNL� u,
<br /> s i AEPAIRrAD01T10N❑ DESTP,U4TION G (No sepnc system r/ aur fyir
<br /> InaratlaifOn will aerie: Residence
<br /> Number of living unite: — Commercial permitted it pr,blie sower is
<br /> Other evadable within ZOt)feet.l
<br /> Charurer of Number of bedrooms
<br /> aoif to s depth of 3
<br /> E•a SEPTIC TANK
<br /> PKG. TAEATM Pt-r.
<br /> TYPe/Mfg -- Water table depth,�
<br /> EN7 P_TLl, Capacity
<br /> �—�- NO,CQmpanmsnts
<br /> Distance to represt: Wr;l1 Method of Disposal
<br /> Founaarfon
<br /> LEACHING LINE ----- `�� Pr
<br /> I Operty Line
<br /> l FILTER 6Ep ` NO,&length at Iires
<br /> f.1 Distance ro nearas:: Well Tcrzl fang;h/sire
<br /> °pundaaron
<br /> SEEPAGE PITSI l De a Propeny Line ^
<br /> If SUMPS p n
<br /> DISPOSAL PONOS Lf Disuntt to nefrea{: Wall ~ Number
<br /> ^-�� Foundation
<br /> f heraby canif Property Line.
<br /> y that I have Prepared this app;:c,non and that to
<br /> rules and reguleticg,Ons al tris San Joe Seun:Y a work wilt be done in accordance wi{h San '
<br /> Homa owner or licersetl agent's s,
<br /> employ ane Bnalure ca"'es rho folfowin Joaquin county ordinencas,skit laws, and '
<br /> - penton in ouch 014?ha'or as r tXCOma alt=,;eCr to wa� fRmpenad tiny}dtVa o!%ahtprnia,"
<br /> cerlrfi.s tho falfpwinj that cencr:r.once Qr the work for
<br /> 7 tion levee at Gslifom�,' cenily that in the periarnen;a of the which this perms is issued,I shell not
<br /> t
<br /> ori for which:his permn is issued,I shad aMomlracicf*s hiring '
<br /> pp Thi applicant OI sub contracting signature
<br /> must coq for etl required ins play Persona subject tow,,, eompansa•
<br /> --Sin Poca,orn• CQmplata drawin un !
<br /> B ad Gi+.�' �, �,•,� B reverse side.
<br /> Tt:le.
<br /> F
<br /> Application Accepted by 1 _ T,. IDEPPA T T USE ONLY
<br /> ? Pit or Grout 1nap.ction by — Data
<br /> h°
<br /> Area
<br /> Additional Com Daae
<br /> manor = Firal Inspection by
<br /> ---APFllcact---Return an,Cop,-- Data
<br /> opito - -
<br /> Date
<br /> SAN JOegUIH COUNTY PUBLIC SERVI[ES
<br /> E,rVIRON4ENTAL HEALTH LIC LIC HEALTHEA PE
<br /> 435 RMIT/SERVICES
<br /> N SAN JpAQU]H; P
<br /> x FEE
<br /> INFO AMOUNT Da:! - t30% 2009• ST(x;KTON; - -
<br /> Cs B52p1
<br /> A.41DUhT REM,TTED Cr -
<br /> k,+13-24OAfV.ries, < CASH REC£NEDgy DAT
<br /> r /• QU Gl�l f PERMIT LA0, _
<br />
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