|
1kFPLICAT ION
<br /> �j 9 ��0 70 9007
<br /> - i�V SAN ,JOAQUIN COUNTY PUB' C 111AI.T iA16#3
<br /> o C !1 ENVIRONAENTAL Uid,T]l DIVISI .�Y"ii�tP
<br /> 445 N SAN JOAQUIN, PHONE (209)46 - 0
<br /> P O BOX 2009, STOCKTON, CA 95
<br /> P1,RMIT F IRE' i YEAR FROM DATE41 i
<br /> (Complete in Tl•ipiicate)
<br /> Applleetiot Is hereby made to Sen Joaquin Cownty Tor a permit 1e construct and/or install the work heroin described. Th1e
<br /> f application is assj*e In eos>Fliance vlth San Jnaquln CouhLy CrJtnanee No. 549 and 1662 and the rTulee end Regulations or Sen
<br /> Joaquin County PublicHealthServices. :1
<br /> Jots Addr ass 2_ 'I rna'�-�--•� --_. C.,` Lot SLz.. tree _
<br /> pwnsr's Frame Addrrss _7'V a _—O /\�Cw.Q Prrone
<br /> a
<br /> ' k'
<br /> Contractor r.,R©� LZ�rdd![5.5__ Jr�__.____C 1'_�tC-_—�...-_...�IJC[n5[N0.S 1y_Pnane__
<br /> 'TYPE OF WELLJPLIMP: NEW WELL V-11
<br /> -/ WELL REPLACEMENT F. DESTRUCTION (:)Out or Servi:e Well ❑
<br /> PUMP iNSTAtiA71ON V- SYSTEM REPAIR L? OTHER [i Monitorins Well E�
<br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES __�...___ DISPOSAL FID. — PROP. LINE
<br /> FOUNDATION AGRICULTURE WELL OTHER WELL____=—_ PITSISUMPS
<br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS yr
<br /> a L7!pciustr"el Open Sonom L� 1.lanlnca Ure.of Well frcavation Dia.of Well Ceej�p
<br /> PrOomastic/Private 0 Gravel Pact L� Tracy Type o Casing �.Kc� Specdcaltons
<br /> I'I Public 1:1 Other n Delta Death of Grout 5±at Type of Graul
<br /> t y y k l I luigdlian Y2 Aprxa.Depth I 1 Easletn S.Aace Soul Inst.11ed lny.
<br /> " �4k�1 T Te` oRepair Work Done L7 Type of Pump __Isv� H.P.r0 State Work Done
<br /> Seal iag !dnterisl i Depth
<br /> Welt Destr�clion CJ V4e1:Diameter
<br /> t, , u• '°' % Depth Piller Macerlal i Depth _ ry
<br /> •y: TYPE OF SEPTIC WORK; MEW iNSTALLAT 10-N ' 1 R£PAIFftAOUITinN i [ GF.STRUCTION I I IND saPlr,:system permitted If paLdre wwer rs
<br /> . 1' `'�'?•ra.; "?1, avadah+e wrintn 2L10 fs01.1
<br /> ,� iya ti.
<br /> .:Tz•^�-_ ,-i `1. "- I.rstallatian will serve: Residence_ Commercial _ Other_
<br /> ° .� s.:s i Nu L a Pine.nits:_ Number of bedrooms
<br /> syK Character o rh of 3 feet: �No.
<br /> �Zdopthai Cepa s
<br /> lq"R,a ngci t?
<br /> SEPTIC TANK fl Type
<br /> . m .
<br /> -V -i �?1 f
<br /> PKG.TREATMENT PLT.C7 � � Method of Disposal
<br /> ' , g I re Distance to rtearr..: Weil Foun Prwery U11.0
<br /> LEACHING LINE CI No.8 Length of Imes - Tots?lengiIII lia _
<br /> T �r '•'r tt FILTER BED [1 O'rstanee o• serest; Well FovnoaUon_ Property Line
<br /> SEEPAGE FITS a-. DtI - _ _Sire Number
<br /> SUMPSLI Distance to ret.. •r Well Foundation _ Property Line
<br /> NSPOSA PONDS �O _
<br /> f hefeby,Certify that I have prepared III eppiicatw• and that the wo• will bit Ouns in accordance with Sun Joaquin county ordinances,tuts Isw"+,and
<br /> rules and regulatioro of the San Joaquin County
<br /> Home owner or fit:snsed penYs signs lure oartdies the following:"L certify that in the periormancs n1 1^e work for wfiicfi this petrttit is ipued.I shelf not
<br /> i t '•l - �,empley,any porstrin in such manner as to bocoma sublecl to werkmen's compensation laws of Csl-fornia-'-Contreetor's hiring or sub-conuaciing Ypriatute
<br /> certifies the following:"1 certify that in the performance of the work for wt,ich this permit is issued,I sI•A artploy persons subject to wutknten's cornpanu-
<br /> ,' .,ion larva of California."
<br /> r� V ,y,l _ �_ " iThe ipplLU�mutlr sHquirsA+t>•;,.psctions.Complete drawing M rover"ar e. Q_�� /�{ ,d Sigred .—.a"— Tina: 7 Dale. !L _.7
<br /> a r �
<br /> FOR DEPARTMENT UCE ONLY
<br /> £ A6. aApplieatbn AeceQTed by `^ �.. (' r Arra
<br /> d
<br /> ' ��ts'" a,? 'Pit or o inspection by ata Final Inspection by.
<br /> n �4rSh .
<br /> Ate' xyd Additional Com"nri:
<br /> F
<br /> Applicant - Return all cap!en to: San J�.:qtin County Puhire Health Derr IC-S
<br /> 4},n 9nvironLsunta1 Realth PIrwrilt/Servicers
<br /> 4 ,si-4Et�1!�i,p�•f'"�'N)4 - 445 N San Joaquin, P O Box 2009, Stkn, GA 9.",201 "�/(f
<br /> rr XP.r y
<br /> F"�� 'i2'rn.✓FsMrl *' l`'r GEE K r �L
<br /> AMOUNT DtIE At+IUUNT REMiS7ED - RECEIVED By DATE PI.RMi7'N0. FJU'�S 1,.r,
<br /> INFO c
<br /> y i#1 ,{hf •kryf ..r;1•! EM 13M IItfvth
<br /> .ti.er p� /✓ _ L. �. !/�C✓V� /
<br /> �AL���•R1.e a['�,4t vi'x - '. ��� ,�1,5 yip„ � .M ,... », rs
<br /> 34,
<br /> Zrn'r5F �h ���;��•r„+:�w'�5�.; ':•.r�6�{$}".1�1�i5%.�mow.. ..-t ..� -r - .-. .. .... ,.,x .. ww .�.4. ,.V.f[•..,....a.- .. .-. ...an4.�.,1
<br /> lbw:,.T,{•p 3rY G - -
<br /> F 1,
<br /> •t�t ri
<br />
|