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APPLICATION FOR PERM T. �I <br /> SAN JOAQUIN COUNTY PUBLIJ H I ICES �I r�je Y,0 __ <br /> ENVIRONMENTAL HEALTH DIVES -- <br /> 445 N SAN JOAQUIN, PHONE (20 y 420_4 ;j) <br /> P 0 BOK 2009, STOCKTON, C •�!!�lpO�Tjj - <br /> (Complete in Triplica EINV # y7tg <br /> Appllcstlm is horsey yode,to Bee Jwqule COuntY Por a peymlt to construct and/ S Ai M Z5 <br /> wilcatlon is since 1e eospliaaes pith Soo Jaquir, County Ordinance NO. 549 and 1862 and the Ru1e+ and 3aaulatitna o' <br /> Jopuln County Public Nealth Ser E.-a. <br /> 7L CRY/LL/ ri Lot st sei e:r e.ae <br /> JobAddean � � <br /> ___ Ph. <br /> Andnnn <br /> Owra2a N. -- /5 <br /> T � �i_)l- - -7 Phone r O_ <br /> !! Adarett_ L�<ense No..J=� 2 7 4, <br /> S Contract 'J <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMEf T fi DESTRUCTION Cl Wt or ""fee <br /> Ye 1: <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD_ PROP LINE —. <br /> FOONDATION AGRICULTURE WELL ._ OTHER WELL PITS/SUMPS _. <br /> INTENDED USE TYPE OF WELL PROBLEM Da. of Wae Casing AREA CONSTRUCTION SPECIFICATIONS <br /> [I Tr d nw CI Oper.flouorn 13 Mantas Aa.of V""Eruvalion <br /> { CI II GpMIC(P,iv1a ❑Guo"Pack Tracy Typ i of Specifcations <br /> _= <br /> II ppor.1 Otlar n Delta Depth of Grow Sul Type of Grout <br /> Inpsllcn IiI <br /> '. <br /> _Approx. Depth I I Eutxn Su,faa Soul Inndkrd by <br /> Ropes,Work ps U m <br /> Type of Pup M.P. Sure Work Done <br /> Deno _ <br /> Ssa11K frGrlal. A Ikpth , <br /> Woo Destruction O Wall OMnatx illar Material A Deytb — <br /> d Depth -- _ <br /> 4j TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ DDITION OESMUCTION 1 ft N. la 'n.�e f„'''+•r I C"WK s•'^ <br /> +j Ilr»4tIon vA neve: liesdonce �/Commxvol Other— <br /> Nun" <br /> ther J <br /> Nun”of L iiV txrta:/ Numhx of Ge irocros J�O <br /> Cora, "N•,,Of o In s depth of 3 Wt: w,I+, ubq dsptn <br /> {? C."CItY NO. L"Pdrnlento <br /> + SEPTIC TAINIX PK8L TREATMENT PLT.❑ •ry/Mfg Method of Diepo»I -. <br /> pxtu <br /> Dito nexeat: Won / Fpundllipn Property Line <br /> f <br /> LEACHING UNE No.S Length of liner - Total Hnpin/n6a Yf F — <br /> '1- Foundation IA 1 Property <br /> FILTER 8E0 O DietorKe <br /> to rwrax: W°N�=O-- _ <br /> / u <br /> p SEEI AGE PITS DepthSi» lfueMar <br /> --i-- <br /> SUMPS LI Dixance to Foment n: WW FoueWaiwn JO a• Pro *m 0- <br /> t DISPOSAL PONOS ❑ <br /> I hereLy art3y that 1 nave PO,,n,this Wpkation and that he work will be nor+•at accardencs with San Joaquin county ordiMncx,wu�- <br /> ruga aro eog,Astipea W da San Joaquin caunty <br /> OI Ca <br /> Io workman <br /> Ne,y ownx a item"sgxR'e eip,a,um anile the loaowinp:•'1 aNfY thx M the wriomisncs of the work for.ul.�cn rho Pormt a iuu+.+. <br /> F xnpwy n n such mMVar u W IRSCe»I lkn)fs l s a <br /> COmpenal•ie1 lw's Nl er". <br /> 'Contrk.loi,M1 <br /> my pmOil inO ur wtrcunba<n•u <br /> C cxtMEr ma fosafk ng:•'I artily thaten the Pedwop nce of the work for which this parent is Ranted.I nholl.0-PI-1 s„ycI m vrorkn•r +- <br /> floe,tears of CMNenll." <br /> The appkcan[ .Nl le 'rEq�Napac,none.Compista dnwnp on rwnr»nin{q/� /�c, <br /> Siead ILTitle: pa <br /> .� �i l __ n: t ic.zl ... <br /> FOR DEPARTMENT USE ONLYApplao1 _ <br /> tron Aupled by Dxa I CI D Area 1 -- <br /> 6Grout Ir gectbn by � en, FnH Impec4on by <br /> L �yl?7— 1Da.al <br /> AddhlonN CoYenmts: <br /> Applicant - Return all copies to: San Joaquin County public Ilealto Service. <br /> Levtroomental Healte Perml VServi tee <br /> '1 1� sad N Sao Joaquin. P O Box 1000. Stke, CA R'-sin <br /> ✓{ IF AMOUNT Wf AMOUNT REMrTTED RECEIVED PY _ATF PERMIT NO, <br /> WFO <br /> .e.>„eaay.I,•., //�in`i l! .Q1 lC lei <br />