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"PLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC REALTR SERVICES <br /> ENVIRONMENTAL REALTB DIVISION <br /> P O BOR 2009, STOCKTON,_ CA 95201 <br /> (209) 468-3447 <br /> vR[�IT szn IBES 1 BAR PAOY D Tp E ISSSISQ <br /> (Complete SD 1 regi State) <br /> Dy Frda to Sao Josqu:o Courcy for a permit to construct and/or install the Voris series. described. Th1• <br /> Application 1. n<re - <br /> Apylleation 1a rd• In eupllance with San Joaquin County Ordinane• No. SN9 and 1862 and ins Rules sod Rqna ulacloof em <br /> Joaquin County Public Health S•rvlca• <br /> Jot Address , City2 !- Lot glee/Atresia <br /> !J /t NVt 9/Add;e7;y 4 •'�( � —_ Phone <br /> Owner's No— -fM <br /> LicenseNo. Prone <br /> Aeeress - <br /> NEW WELL ❑ N ELL REPLACEMENT l7 DESTRUCTION ❑Oat of Service Well Q <br /> TYPE OF WELL/PUMP. -� OTHER ❑ Monitoring; <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> SEWER LINES DISPOSAL FLD.— PROP.UNE _— <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> —�� FOUNDATION _ AGRICULTURE WELL _— <br /> b INTENDED USE TYPE OF WELL PROULEM AREA CONSTRUCTION SPECIFICATIONS_ <br /> Mannce D.M.of Well Crib" <br /> ❑Open Bottom ❑ Die. OI well Escwnbn <br /> ❑Indualnal $pecilKatbna <br /> TMD•of Cuing <br /> U Oomotk/Privet ❑Greer us"a Pack ❑ Type of Grout <br /> L Public <br /> i� I:1 Other ❑ aue Deotn d Grow Seal <br /> ❑In"non _ADaos. Depth ❑Eulur. Starlet,Seal Installed by <br /> T of Pump H.P.�---- Suit,Wort Done <br /> Reps ir Work Done L) roe Sealing material E Dept?, N� <br /> WX Devructbn O Well Diameter Piller Material a Depth CA !, <br /> Goth <br /> }" - .TYPE OP SEPTIC WORK: NEW INSTALLATION REPAI RIADDITION DESTRUCTION G (No septic <br /> 200 last ad it DubIK aew+r IF .. <br /> (!l <br /> Commercial�L Other i <br /> . Im!allation.Mil lo"! Rnid•ncs_ <br /> Number of NMng unite:_ Nu. ]ar of bedroom Water table depth <br /> ' CMrKIM of epM to a depth of g feel: No.COMPanrMnte { <br /> t SEPTIC TANK - ❑ Type/Mfg Cspac tY <br /> i Method Of Oieposal T, <br /> PKG.TREATMENT PLT.❑ <br /> FoundationProblem,Lim <br /> Divorce to nasrasC Well 1'S <br /> S <br /> r. <br /> alb No.S Length of linea r,Tytal IangNhia . <br /> LEACHING LINE ❑ D FOundvioil�..e7 :I.— PrownY Line <br /> `vr FILTER BED i ❑ Distance to naa.uC Wall . <br /> kj <br /> 11 Depth Sir•_ Number <br /> SEEPAGE PITS Property Line <br /> SUMPS11 - :I Distance to m~ Wan Foundelion <br /> ta _ <br /> DISPOSAL PONDS ❑ <br /> ... <br /> I rwbv c•n!M roar 1 naw prepared in application area that the work will be done in accordance mann San Joaquin county ordmancea,stat•lews,g Sig <br /> and <br /> roles and regulaNens of the San Joauuin counts 1•haX net '. <br /> Nome owner or licensed ag•ni s nonature wni:les this lollov.mg. "I cert fY that in in*Penormanc•of the work for wnicn in D•rmt a naued, ftatu <br /> -employ any pyepn In n:ch manner..to become wOpct to workman's compensation 4wa of C•lilprnia."Convactoaonaes lavbpct W yrortrrueY cortwenaa <br /> �- eaAflea the following:"I certify that in the performance rel isle work for wnicn this permit i•ioued. Nan amP oY W �1 <br /> -tion laws of Collf"If.'• <br /> The applicant must u/M for all reouind/Msopec�tbm. Compete dnwim)on royal"tido. - )� •� 3 p/ <br /> Dais: <br /> Signed x <br /> �.f/'(.� G- v �!2-=G✓E'il Title: <br /> n /FOR(�DEPARTMENT USE ONLY yr^� <br /> Application Accepted by <br /> --IF/L/ hGEJ /]M.vl Oen� } Asa FO L <br /> L �� Dau=2 � <br /> pit er Oreul inspection bV 0.,,. Final Inspection by — <br /> AddhbnN Commsnu: <br /> aQ�weF� e 43f- /— a <br /> h .AppUNTY PAILIC 11"ni SERVICES <br /> llcart - Reture all cOplas W: ENVI JOAQUIN <br /> UNTALONSALTN•L`1VI8xON PMIT/SERVICES ' <br /> 4e5 N SAN JOAQUIN, P 0 BOK 2009, 9TUCILTON, CA 85201 <br /> FEE AMOUNT DUE AMOUNT nEMi1TE0 <br /> RECEIVED aY DATE�(-Ocuo <br /> INFO <br /> '_ IS <br /> W t <br /> .- <br /> UV..Y? <br />