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S.%N JOAOUINCOi NTY PUBLIC HD\L:j- VICF <br /> % ' <br /> EN iVIR <br /> 0Ns,1EN7AtA1EALT1[D:V& - alb 4..45 N SANJOAQUIN.PHONE(209)469-3420 <br /> I <br /> 110 ROX}SS,STOCKTON,CA 95201.038-8 7-AJ IF <br /> PEEWIT YEAR <br /> FRQM DA:,;E <br /> (Complete <br /> (Complete in Tripl-Icate) <br /> his 2PPlicill"'r.is ma !in can-P;ia�ftcc with San <br /> made In San Imquin Cnull!v(0 3 1'ernn" int:01 he cork�.:ml drscnt <br /> Application is hcrthv R R?guivitms of San jm4uir;Cou"M Pumi;Health S"Ices <br /> J03(:uin County Dcv,iopmen:Tiil- 2 N'SC�';i-�n and t�e Vle%and C'ci I C) AV" <br /> Cc <br /> fz­11 <br /> r�if <br /> - <br /> Lot-SS Rei Acreage <br /> Jot,AdCreas j 6'_1 <br /> Phan. <br /> 0-inef's Name <br /> c-fets License No. P-'ome <br /> Ccr:iatio,ru!tl DESTRUCTION �-.Out of ServIce Well CI <br /> FyPE OF VIELL,PUmp NE.Aj WELL WELL AEPLACOOENT mirittorl-4 Well (3 <br /> PUMP INSTALLATION SYSTEMREPA!R OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWED L:NES - DISPOSAL FLU. PROP.LINE <br /> FOUNDATION AGRICULTUAE WELL — OT)4ER WELL PITS/SUMPS <br /> s. TYPE OF WELL <br /> PROBLEM AREA CONSTRUCTION SPECIF!CATtONS <br /> INTENDED USE oil Caving <br /> C industrial 0 Open Bottom ManToca D.A of I.Va);E-csvaDon D.A.of <br /> CI Domestic/Pinto U.G'AV*I Pack TrALY Type of C23,ng-— Spalicificilicint. <br /> -1 Detia Depth of Grout Seat Tvpe of Grout <br /> l'I P�'blic othe: VA <br /> Depth 1 Ealiom Si.irlAcii Seul Installed by y <br /> i Ao"k. N.P. State Work D.R. <br /> Rapai,Work Done L', Type of Pump Se&lir%g haterlwl A Depth P <br /> Well Destruction 0 Well Diameter UL VZ.8 1QQ1A <br /> Derillit Filler Material 4 Depth <br /> fADDITInN iis <br /> DESTRUCTION I i <br /> NEW INSTALLAT <br /> TYPE OF ScP TIC WORK ENvr_I�q;1'144 <br /> A,HEALT14 <br /> Installation v.+0 so"! Residence_"' commercial Omar <br /> ' units:—.L- <br /> Number of bedrooms A/ <br /> Numbef of I'ving <br /> Water imbis depth <br /> Chgroetaf of oag to A depth Of 3 104V &CL40aC2 <br /> :'f L I Capacay (A No.Compartments <br /> SEPTIC TANK Method of Disposal <br /> PKG. <br /> TREATMENT PLT.C1 D;s1ahca to nearest; We . //1,i, Foundolion Property Line >� <br /> LEACHING L$NE LR! No.&Lenalh of lines mr_Zza r Total langlKlaize 12 <br /> /_�O Fou,icanon Property Lino > " 21 <br /> FILTER BED .1 Distance to noareilt: WaIt 'P, <br /> SEEPAGE PITS IK Depth Size Number <br /> SUMPS LI Distance 10 n8&f*s1: Wea X41Q2' Foundation> L,'L Properly Line <br /> DISPOSAL PONDS <br /> 0 <br /> I PulfiabY Cofl?IY that I have PFGP&Fgd thrill application and hat the work will be(lone in accordance with San Joaquin county ard,n.an"s.state Iowa.And <br /> rules And regulations of the San Joaquin County "I certify that in the pe,form*rce of the work for which this permit is issued,I Shelf not, <br /> nit's signature cvrjif�a*the followinQ: <br /> Ho--id oyner or liceriW$98 become Subl*CZ to woekrori'a compensation Iowa of Cafif6riis Contractor's h000ng or SWb..c*njracjin9 aignaturis <br /> employ any person in such mannal as to <br /> certifies the following:"I certify Ihiit in the peformance of the work for which this permit is issued,i @hall employ persons subtecl to wairk"n't.compen" <br /> lion Laws of California-', <br /> The apalicen.mull call for all required inspections. Co.--rigive draw,ng on reverts%-do, <br /> Ar�z <br /> S;gnod Title- <br /> '�.k'r- �� FOR DIEP ARTMEN USE O <br /> NLY <br /> lo z <br /> Area <br /> Application AccepT44 by <br /> .A Oats F,r.ol Inspection by, <br /> Pit or Grout lngvocl�On by <br /> Additional Comments: <br /> Return Lit CUP!�G to: Sa"t Jo'qU"-'County Public Health Services <br /> Aprltcmnt En,ironmentall Health vermitiservices <br /> 445N,San Joaquin.P.O.Brix 388.Stockton.CA 95701.0389 <br /> FEE AMOUNT DUE A NkOVNT AE MI-TED a5 RECEIVED BY DATE FfAMITr NO. <br /> NFO <br /> 0- <br /> REV.. <br /> . 1-11 4, <br />