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APPLICATION SR# t1 I <br /> SAN JOAQUIN COUNTY PUBLIC <br /> ENVIRONMENTALAyZ's{j SERVICES <br /> SOO({ <br /> IIEA?TH I�I�18t•7 <br /> 445 N SAN JOAQUIN, PHONE ( )/] ,1420 <br /> P O BOX 2009, STOCKTON, tdIOT _ <br /> PERMIT R � <br /> (Complete in Tripli <br /> Application Is hereby arils to San Jteeuln County .•or s perelt to construct and/or Install tl.e work herein described. n,. <br /> spplltat:oo Is soda in Ccapllance vfth San Joayuln 'avmty Ordnance No. 569 and 186E and the Rule. and P.cu ationt of Pan <br /> Jowuln County\Public <br /> Health Services. .}. <br /> — 3 �_ Con,_I_. �G <br /> Job Addy.., 5�55'o RO Con, ReY Lot Slse/AeresSe <br /> Oworb hemlag(`/^DIn) So M�-S Addicts Phone <br /> r• It'4- 14J_Address--ba- <br /> Contractor _�6X (rS6 Uaense No.�YSY A� Prone "t`-7173 _ -t <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT n DESTRUCTION LT OUT of Service well ❑ { <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR . OTHER C Moditorlpf, Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO._ PROP. LINE ; <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �. <br /> ❑Indunval ❑:Open SORom -❑ Mameo Du. of Well Escevarlon Db.of Well Casing <br /> T)Domestic/Pr'wne ❑ GraM Pack "❑ Trsey----TVq of Casing- _r Specifications <br /> I'I PuMit 171:01h., fl Dlbs Oeoih.1 Groot Seal •r - - Type of Grout ?' <br /> I I InRtaUpn ApMoei Depth I I Eastern SuAace SNI Installed by <br /> Ragl!Work Done U Type of Pump• ""N:I'---I _ State Work Dor1e <br /> WeR DeseNetion ❑ Wall DMoratX _Seallsy llats+inl-t Depen: _ i F <br /> Pt llar Material A Depth'.: t •r ; <br /> .} REPAIAIADDITION DESTRUCTION I I (No"now ysism grntitt"d public k,was,E, r.zt <br /> I I TYPE OF SEPTIC WORK: NEW INST LU71n'.:+-. <br /> 1,L� ,/ available within 2001NI.I �± <br /> { F ~•TNIa�lltbn Mill Nrv..-Flmldanu Commertul_ Other <br /> - Number of hiringuhib: h. Number of bedrooms <br /> _✓ CHA.aaur of loaf to a depth of 7 Mt .q YTK..P_ I <br /> t Water fable depth <br /> SEPTIC TANK V�TVps/Mfp L L Ccooc(tF< CapeClly qnt56 NoCempartrab <br /> 1 PKO.TREATMENT PIT. �• �f_tl, <br /> I <br /> ❑ -., r t lI ,MnMd of�yDbeeeal y 1 <br /> (Distance td its Well��_ Founw <br /> dation I S i Property Li <br /> ono, <br /> LEACHING LINE GT-No.b Len In of linea - D 0 <br /> b J } g Total length/site <br /> FILTER SED ❑' Distance to neeresr. Well f R fi_ Foundation i r t Property Line SO <br /> SEEPAGE PITS 11 IDepth -I Sire_ Number_ - <br /> i 'SUMPS LI Diabnca 1.heeteel: Well Foundation �� Property,Liu : <br /> DISPOSAL PONDS ❑ <br /> 9erebY Ca iry that I hila prepa!ed this applocaliun and that the work will bar um done in accoroan`a with San Jgucounty of financial.state letK end C. I <br /> 'rube and requletiurle of the SN Joaquin County _ -• .-'. I -- <br /> Nwtle owes or licensed apent'e signature comfit,the following:"I testily That in the gifwmN •of the wort for vAkh This permit is blued,I shah <br /> ten n <br /> } employ any peosuch manor as w baenw aubllct to workman%compensst on birE of CaN.'rw."ContractWs hiring oiwb-epmraetbn2 Sig", <br /> 1 f"cenRlss the following:'I certify that in 1M perlwmil of the work for ich this nemit is issued:I still employ sa arna subject to wurkman's comgnss �. <br /> ebn;bws of CalMomlo.•• <br /> The'applicant must call 1w W COmpbta dowing on guests etch.'- <br /> i <br /> Siprrd x Tilu: E�� Date: <br /> J <br /> FOR DEPARTMENT USE ONLY } <br /> Applieatbn Accepted by �j1_� 1�1=�'t "`-r Date_j], Area 7 I����j <br /> niMOW '1 PH dr Oscuf Inapeetbn by Date Final Inspectbn DY DYDau .. !i t <br /> MR <br /> 4 th ,, Aft4lo sol Cwnmenu: <br /> Applicant - Return all eoplen to: Sao JOagvin Pounty Poulin Health Services <br /> 'AdyYjY ., e_5 iN SanastRI Joaquin,Heath <br /> To 0 B.t2009,•l Else, CA 05201 FEE <br /> asp itS•kJ �`(.`pc•,/I INFO AMOUNT DUE AMOUNT REMITTED C^SH. : RECEIVED Fv DATE PEAMIT-NO <br /> �t j •1 EN te)♦ _ <br /> 1 1 <br /> { <br />