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3:CO APPLICATI04 FO[t PERMIT S� SAN JOAQUIN COUNTY PUBLIC: HEALTH SERVICES ..SFVIRONKENTAL HEALTH DIVISION 1601 E. HAZXLTON AVE. , PRONE (209)468••9420 P 0 BOX 2009, STOCKTON. CA 9-201 �fiRisTT FxpIRBS 1 _YFeR ��LDATB_I9SSI�p. �� ,. (Complete in Tripliemte) Appllcatfon 1a hereby ,r+dr,to San Joagi:ir C,..nty for a permit to construe' end/ar laete_,1 theAvroe` herein desLl�do= This opplleatloo ie ,aGa in coWllanee with Sni Joeq•:1n fourty Ordinance No. 547 and :86? .:td tht (:SL3a Joaqulo County Public Bealth Serrlees. 4 �� - —wr�Pr=nP.�7 ICA Cty S1 it.t Size/Acrealte %Z" =+ Job Address J R 4 1 13/1L�G1�_ Address-Lr7 4 _.�— _._�... Phone L.r:er'a 41, Name -- -.. cL:1r-S+D WO,B17--RCC:ess.�IV_s�p h,rY.rs�=�.��7r�r.Li:ens�No. Pone .3. ;YPE OF WELL;KNO: NEW WELL 0 WELL REPLACEMENT f 1 DfSFRUCiIOfJ C1 Out of Yrrv3Ca Mr-1 1 �._— PUMP IriSTALLATION ❑ S YSTE-.f REPAIR ❑ O'''1ER ❑ xonttetitl6 Sae 1,:l7 a OtSTAntCE TO NEAREST, SEPTIC TANK SEWER LINES __^ _ UtSP05f-L FLO. PROP. LINE f; Y C�- FOUNDATION AGRICULTURE WELL OTHER W-LL PITS.'SVMPS INTENDED USF. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ Die — DIa.of WO 1;Indiavel 0 Opera Bottom ❑Manteca . of v.'eu excavation�� Typo o!C+sir.9 _ Sfi►cifkafions > 1S Dom:esticlPrivets ❑Gravel Pack ❑Tfscy - 7r0e of Grow Pubk 1.1 Other nDotts Depin of Gout Seal - [ Appeal. Depth I I Essleen - Surface Seed Installed by rga:ron Repow Wo•t Done t3 Types of Pump H.P. _ Stare Nn+.. Gone 1 feeling Materia' i Depth w'ett Dtstrrct�&- fJ Weill D;.rA'w �� Tiller Pasterttl a Depth rmim-d if rbtK Newer A ' TYYE�O:SfPiJC C RK: NEW INSTALLATION 1 1 REPA1RIADOITION OESTflUCTION t I =Swb Kisr t sale ref 1 P' - Insta4tion will sane' Rasdanca�Come»rcial_ Other - e . _ - Number _rvinp wrtr.�_ Number of bedrooms 3t - -- Charader of sol to s depth of 3 feet: _ Water table depth Csvaciry _. Na.Contpartrrrrnq' SEPTIC TANK C Type/Mfg .. PKG.TREATMENT PLT.0Method of DiSPOW y` Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No 1k Ltngth,of lines _ - _r Total length/aua ' FILTER BED n Distance to nearest: Wel 3 stn Foundal on Property Line 1d _ _ r rNumber SEEPAGE Pti It Depth _j,_Size S':fuPS L! Distance to nearest: turn ea- u FondarionProperty Lire DISPOSAL PONDS ❑ �. 1 Fareclr Certify:hsl I Meme Wepared This application and that Ins work will be done in accordance with San Joaquin county ordinances,State Iawe,end . rules and regufalkw s of the'-on Joaquin County 1 shall M� 3 Mpne owner tit lica,nsad a,T+nl'�s+gnatuie drtrfies Ihe foaowing:"t Certify that in the performance of the work for Mf..Cy thin perlrtit h iewed,- :1 Hopley any perlorl;-slrch.ryrlryr as 10 become subject to workman's COmlpenssoon laws of California."Conlrsctor'a hiring or suKPAnlrMing elgrWIUFA certifies fly'olk7+h+ng:-I C+rrt+fy that in the Parfetmynce o1 EM worts for wfikh this oermil is issued,l shall employ poisons fublecl 10 workman's CrJlrlpar so- 'z floe Owe of Cahlrartie." : The applicant must Call for 10 requ"d'++ flora.Complete draw+rtp on reverses side. - c Signed Titta: Deter ' - 1� c FOR DEPARTMENT USE ONLY ,4t AppYeatbn AecapM1 by 4 Dase _ Arw Pit or Grow,Inspection by _ flats Final Inspection by Date 1.:. . A k%WW Comments: �. .. Applicant - Return 1911 copies to: [:an Joaquin Ca-IpL7 Fubllc Hewlth b'crrieaa, YaritOrmental Health P-colt/5errlcn 1601 Z. Hatelton Ave.. P 0 Bax 2009. Stoekten. CA 95201 `. �i r,e FEE APACII)VT DUE AMtlVNT REMITTED CASH E RECEIVED By PATE l INFO i .t.13-24 t1"'r. / y OD SS• II�� /~"I/ 2! 10 ..