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APPLICATION FOR PERMIT <br /> SAN JOAQUIN CON" PUBLIC HEALTH SERVICES <br /> ENVIRONKE NTAL -HEALTH DIVISION <br /> 44$-N SAN JOAQUIH., `PHONS- 000468-3420. <br /> _ =- <br /> T-0 BOX 2009,� STOCKTON, CA 95201:- <br /> VQ- <br /> I R.B X RWED <br /> (Complete in Triplicate) <br /> 1Fpl1catlon it heretry made to Ban Joaquin County for a permit to conatruet�and/or Install the vork herein described. .Th ia <br /> applieation is made,An compliance with Baa Joaquinouq _ Ordinance no. 549:and 1862 and: the Aides and-AeAv]atlon• of San <br /> Joaquim County:'Public-Health Services. "�C110 t, -{rlprtr4e n req t, <br /> inti Add rsfa. W� City Lot SIze%Acreaae <br /> Own•r's;N•me 3644 ...Address' Phone <br /> contractor - Dr'lm Address License Ne. Phone <br /> _.r VPE OF W£LLlPUMPr, NtW WELL WELL REPLACEMENT-n :DESTRUCTION.0 Out of Service well .CI <br /> PUMP INSTALLATIO ❑ - SYSTE REPAIR Cl OTHER ❑ Monitoring well. <br /> DI5TA_iVCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLDOV/&—.PROP. LINE/U. � <br /> FOUNDATION AGRICULTURE WELL= OTHER WELL PITS/SUMPS <br /> i?VTENDED USE TYPE OF WELL <br /> _ __ _'PROBLEM AREA_ CONSTRUCTION SPECIFICATIONS � <br /> 14 liidustnel ❑ Open Bottom Manteca- . Dia. of Wifl Eaavalion Dim. of-yVeN Casing� <br /> Oorneefic7Priv1• ❑ Gravei Pack 0 Tracy-= `Type of Cssino_}V-C - Specifications - <br /> i I Prrf+Ilc! C]Other. _ f1 Delta Oeoth of Grout Semi _ Type of Grout_ <br /> i s Ir�ft,arion _ApOror. O•prh- I I-Eastern Surtsu.Soul Inaall•d by I; - <br /> Repair Work-Done Ll Type of Pump .:H.P"-.. State Work Done <br /> 'Well Deettuction D WON Diameter -9aling Material i Depth <br /> Depth : Fi`ller Material-i Depth <br /> TYPE OF.SEPTIC WORK: -NEW INSTALLATION 1 REPAIR/ADDITION Ia DESTRUCTION I I INo <br /> alptic syst•rn t]ermnI"i# public sawn r§ <br /> available within 2W feet j: <br /> tnstasafion wile Serve: =Residence, donr•nercial Outer <br /> Nurnhw of Wing units: Number of bedrooms " <br /> Character of and to a-dooth'of 3 feet: Watt table depth <br /> SEPTIC TANK ❑ -Type/Mfg Capacity No. Compsrtnsonts - <br /> PKG. TREATMENT PtT.1[ -Method of 0*1011401 <br /> Distance to nears": We" Foundation Property Line <br /> LEACHING LINE Cl No. b Length of lines Total length-/size -- <br /> FILTER SED 0 Distance to nares": WON . Foundation <br /> Property Lino <br /> SEEPAGE PITS I i: Depeh Size Number <br /> SUMPS LI Distance to nearew: WeN Foundation- Property Line <br /> - U <br /> fSPOSAL PONDS ❑ _ <br /> I hefMv candy that 1 hew}prepared this application and that the'work wiil be done in accordance with San Joaquin county ordinances, sole itws, and <br /> ruins and regulations of the Sari Joaquin County .' - <br /> Horne ovww:oe ticertaed agent's signature candive the following: "t certdy Ihot in.the oerform•nce of'thework for which this-perms"is issued. I lhmN not <br /> . 010"WW-vereon in such mnvsr as to' F a subject to worknian's-compenanon Ur*m of-Califomia." Contractor's hiring or sub-convactnq$I he <br /> tuie <br /> rernfi••the loibwing: "Veortify that'in-the performance of Ih+:work for which this pirmi":y iawd,-i-ahail employ p•raons.aubj•c"to workr+sn's co <br /> *ion taws of Camamis." i.r"nsa.. <br /> The aopicent t 'for an i+"tions. Complete drawing-on cover"side. .. <br /> Signe Title: rJ Data: <br /> Owl$_H4 lRe-0 <br /> FORDEPARTMENTUSE ONLY <br /> Apoketion Accepted:by Date C Ara :� 1 <br /> flit or Grater Inspeedon by Date Final In <br /> . spsetion by �� <br /> Q 1 C7 t� <br /> Addf[ional Coinesnta: 146d <br /> Applicant - fletu all copies to: San Joaquin County Public Healt4'Serviteri. <br /> Environmental Health-Pertait/Services <br /> 445-It San Joaquin,, P .0 Box 2009" .Stkm, CA 95201 <br /> FEE AA60UNT.0t1E ' AMDUriT`RE#tItTED CK RECEIVED my CATS - - PERI4m'No. �V I <br /> I>rto <br /> rH,f.>w �uu1 8 z p-zLI3 01331 <br />