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fir'=.rye• <br /> I <br /> APPLICATION FOR MWIT <br /> i <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRON MTAL HEALTS DIVISION <br /> P O BOX 2009, STOCKTON. CA 95201 <br /> (209) 468-3447 <br /> (Cniaplete is Triplicate) <br /> Thi <br /> ep911eatiba to asadsA"11COLIce to trtb ecrpl�r rishSu ulflan JraaquisoCouar a 6y Otdirsit tetaneeaEo Sk9 and ff3S2 and thaeftulee "d Asslulatioaarof Baca <br /> Iw4uls t duty pubLie IIlo <br /> th�rvi es.s+ 1 2 W <br /> Sty v wt size/Aer4n <br /> Job AddressQ <br /> t ck ti� Address phone�O 93 <br /> owners Home- ' J r��L TT <br /> i tt o,^ Vsh,1-10 'py cl p'k W K f aTt ) w 3 PISDne" - - <br /> Canuaclar b ifs "DA.01 �+A�'drsfz C r Licenzr No <br /> 1fPE Gf WELLIPUMP: NE'hl WELL O WELL AEPLACEMENT 0 DESTRUCTION ❑Out of s*Tyle• ffe11 <br /> PUMP INSTALLATION 0 <br /> SYSTEM REPAIR 0 OTMEK 0 tkaaltoring yell <br /> DiSTANCE TO NEAREST: SEPTIC TANK '�"����y"N���Sw�`-� SEWER LINES _ DISPOSAL FLD. PROP.LINE <br /> FOUNDATION IC�fsS� AGRICULTURE WELL OTHER WELL PITSISUMPS .� <br /> INTENDED USE TYPELi PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open Boston 0 Me.rteca Die.of Wall fssatration Dia.of Wen Canine <br /> Type of Ca' k�� Q SDacilea:tionz�;._�—.- : <br /> QT DomesticOval 0 Gravel Pack C]Tracy z"`9S- �sr— <br /> p j?I therM•W.Svw C I']Dalin Depth of Grout Sell 19-101 Type of GrouL '^"^ <br /> - M1Gt•1Qrt� t '� Ka r 1 � S <br /> M IVAppros.Depth n Easlan Surface Ssal Insntted by r <br /> Raw Work Dona EJ Type of Purnp;yONE M.P. At NL - State Work Cone_ ^ <br /> WIN Dennwetion 0 Wet Oismarer ffeelittg Itatarisl A Depth <br /> Depth filler flaterlal i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIDN REPAIAIADOITION fZ DESTRUCTION G ;�tkANtciytitl++�.200 lifltled d puWK$ower <br /> is <br /> fnetah4tion vein aarre: Residence— ComrnerrW_ Olhef <br /> Numbs of Iiyirt0 unite: Number of bedrooms <br /> Character of soN to a dao h 0 S teat: Water table depth <br /> SEPTIC TANK 0 TWO/Mfg Capacity No.Compere inn ,..`.. <br /> PKG.TREATMENT PLT.0 Method of Disposal <br /> Distam to nearest: Wall Foundation Property Line <br /> LEACHING LINE ❑ No.&U-ngth of linea Toltl length/size <br /> FILTER BED 0 Pittance to neerast: wen Frundnwn Properly Lina <br /> SEEPAGE PETS I I Depth —�._S@e Cumber <br /> t SUMPS LI Distance to rarest: Wok _ Foundation ProWY Lina <br /> DISPOSAL PONDS 0 <br /> I hereby Comity that I have prsperod this application and that the viork will be done In accordance with San Joaquin county ordutances.state tawil,and <br /> rules and regulations of the San Joaquin county <br /> Mome owner or konsed a¢ant'e signature��w��rifies the loGow+nq:"I ceniPy that in the performance of the work for which this permit is iuued.I aMn rat <br /> employ any pwwn in such Mannar at to bm"o subject to workmen's comoensalion laws of California."Contrectw's hiring Ow sub-CpnUactinq siaAsture <br /> certifies the toadwing:"1 camify that in the performance of the work for which this parrt0t is issued.I"it smpioy persons subject to worilf"A'a corn AW <br /> tion laws or CMlfornll." <br /> The appliesArTnuat CONAWaquiredrjnzpetlkm.Comptile drawing cn else side. <br /> SiarMd l l!'i�� """ Title: orDau: <br /> FOR DEPARTMENT USE ONLY <br /> /[J�/ Arse LLIs_..r <br /> ' ApWkstbn Accepted by �•/1iC.A.t � - Das. /! 0 <br /> ---- — — --- —D --- -- -Final lnspsctian by Dna <br /> Pp w Groiwt 4tepaction by: ata- _ --_-- - -- <br /> Additional Cornmenta: <br /> pplic"t Re%.urn all aoplea to. SAIL JOAQUIN COUNTY PUBLIC ASAL'TR`9 COU NW-?[DSLICIB&THS&V= <br /> J ENVIRONMENTAL UMT0 DIVlsion PSUIT HMrdDMEOH <br /> 445 M SAN JOAQUIN, P 0 BOX 2000, 3T"C1 k <br /> . - NF :-AMOUNT out AMOUNT ReMtTTEO CASs+ RlCG "W.. <br /> - .. <br /> INFO `jl'{�) y yJ� <br /> .. i <br /> IN r}7f lRty.te�fi vyj,/Vi/ l��J.. (, �-1 4 <br /> IN 13.24 <br />