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4 <br /> - ry <br /> d <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVILONMENTAL 'UALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> w <br /> PEMIT E121HEs_ 1 ,JEARR, FAOki pA1S_LaX 5D <br /> (Complete in Triplicate) <br /> Application is hereby made to Sao Joayuia County fur a permit to construct and/or lastall the work herein described. This <br /> application 1a made in ecmplisnce with San Joaquin County ordinance No. 549 and 1962 and the Rules amdRegulatic a of Ban <br /> Joaquin County Public Health services. i1 <br /> JabAddrsas COLAITJI(, tf-A �� _�� City "IC.�UL14 12 Lot size/Acreage <br /> Owner's Nam! Address Rqk,-k CJ(t' w t Phont����J <br /> • Contraeta+•J e,6fru/r7 _Address �E'�h C 1 "/f1' S7,License No. Pnnne y'1�44-3 <br /> TYPE OF WELL,PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Out or Service well Ll <br /> PUMP 1NSTALLAiION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well X <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLD. PROP.LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> rl Industrial ❑Open Bottom ❑Mantees Dia.of WON Excavation Dia.of Wolf Casing <br /> U Domettic/Private 0 Gravel Pack G Tracy Type of Casing Specification■ <br /> ❑Public 1:1 Mhar ❑Delta Deplh of Grout Seal Type of Grout <br /> CJ Inrgavon —Approx. Dept`+�❑Eastern Surface Sao]installed by <br /> Repair Work Done U Type of Pump _ry i_t H.P. Sista Wor Done <br /> Was DsOructlan A Walt Diarrarert��-- Ssa,ing IAtarinl i Depth lie <br /> Depth 3d — Filler Ffaterlal L Dept0)-1z <br /> TYPE C:SEPTIC WORK: NEW INSTALLATIDN Ls RE /ADDITION C1 DEST CTION Ll (No sepue syslerei perminsd it public server is <br /> available rrhhin 2f>0 feel.) <br /> x In2I1Nat;0M VAN sorve. Residency— Commercial T Cthct <br /> Number of living units: Number of bedroome <br /> Character Of SON to a depth of]feet: Water table depth <br /> SEPTIC TANK ❑ Ty"Imfg Cspsfity No,Comperimanta <br /> PKG.TREATMENT PLT,CI Method of Dispoesf <br /> Dlnanes to nesresi7 well F ndation—. Property line <br /> LEACHINC LINE Ll No.5 Length of lines Taral length/size <br /> FILTER BED 13 Distance to nearest: Wali Found ion Property Line <br /> w <br /> SEEPAGE PITS 11 Depth _S <br /> SUMPS Lf Distance to r+Mresl: all Foundation Property Lira <br /> DISPOSAL PONDS ❑ <br /> i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joa4uin county ordinances,it laws,and <br /> i rules and regulations of the San Joaquin County <br /> Homti owner or licensed agent's signature comifiaa the following:"I certify that In the performance of the work for which this permit is issued.I shall not <br /> employ env potson in such mMMr as to become subject to workman'•compensation laws of Calaornis.-Contractor's hiring at sub-contract:.C s+gnature <br /> certifies the following:"I certify that in the performance of the wort for which this permil is issued.I shall employ persons subject to workman's comnanss- <br /> ;, Ilan laws of California.- <br /> The applicant must call for aB required Inspections.Complete drawing of reverse Side. <br /> Signed Title: il1111'r 1plp- ._._. Dale•, z <br /> FOR DEPARTMENT USE ONLY <br /> Appl.silon Aceyptad by Dote ' <br /> Area <br /> Inapeclbn by-._ _ --- --- Date ----- - -- ------- <br /> _.....�� rm napdctibn by-----—'--- --- Oats <br /> -- ._.Id€tionol Comments: - - - - - <br /> i Applicant - Raw"e11 coPlea to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONWERTAL HEALTH DIVISION PZRifIT/SERVICES <br /> 445 H SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA P5201 <br /> FEE ►MOUNT DUE AMOUNT nEMITTEO <br /> urr0 t ASN ECEiVEO BY pelf PERMIT No. <br /> ,a/t�(�J �fJ/'-�J i 0`7 <br /> rr, �At •Vu/ �c/�/r� - <br /> r r <br /> UTICW <br /> G*M, s <br /> cow <br /> Iy <br /> OF <br />