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APri.ICATION FOR*q1PXRY1T
<br /> SAN JOAQUIN COUNTY PUBM('. 11EALTII SERVICES
<br /> FtiVIAORMENTA1• HF:AI,'I'11 DIII ION
<br /> 1601 E. �d2<vtG AVE. , PI10T'I•' (20'+)456-39'20
<br /> ' P G BOX 3005, STOCKTON, CA 115201
<br /> (Complete in Triplicate;
<br /> ,.;plScetion io her-try mad,- to Her. Jce.euln ^..an:y .'or c jer St to construct %rid,or tna•.ell tte work herein descr:.bed. This
<br /> a}plicetICT2 made In cos}_Sance vSch Han Joaquin County Ordinance No. 5a9-an! 1862 end the Rules and Re Ru ationo of cat,
<br /> Jr-Auin Cour Ly Pub;1c Heal::, Servi¢ee. -
<br /> .. S f f' t ____ Cary� lr_s `�GJ Int 91u/AcrcaE{c• _-
<br /> Jub Address
<br /> J v1,vC Ji.t•1✓Of�/r f( 7 S /
<br /> rr, i"•I ! /I.: /� l A'tldrets -L..x..._'_ .:�-�...t - _ - PT+One! Z.
<br /> CwMrf flame
<br /> ^�� AA''tf5 - _t_G!!_/--1/--� L
<br /> ry-ur. Cuntiacta,1J Ll..�_.�C�. _
<br /> V0 }1 TYPE OF YELL/, �,MP: —'tEW WELL .. V:Etl.REPLACEt!FNT _� DESTRUCTION U Out of 3er+ice veil �.�
<br /> PUMP INST tit.'_71ON 0 SYSTEM REPA!N OTHER G
<br /> Monitoring Well
<br /> DISTANCE TO t'E ttEST: SEPTIC TANI: �r_�_ SMEA ONES _�_ DISPOSAL FLO__.__.. PROP.LINE .
<br /> _--F-UNDATION _._ _ AGRICULTtiP,F WELL OTt+E?WELL. ., PITS'5UMP5 ._ .
<br /> NTFNDED t15F _'t'f E OF WE:L PROBLEM APER CONSTI.UCTION SP-,:IF�CATIONS
<br /> _ __ Dia.O'Welf CLIM9
<br /> iAdustvv! C Opel.Bottom Ca Manteca tAe,. of Wen E. ava ,;n_-._..,_ ---- Specie„ ._ons_---•_---
<br /> ".<- --
<br /> Gores!U Pnvote Cl GnvM Pack l; Teary TYto of Cesrr+l
<br /> i P,Ibtrc
<br /> I.t O,r.Or !t Oely Death of G•ou• Seat -.- Type of GrOO.
<br /> r I in illation Apfyo. Depth I Eaetan Surlace Seal Instanod br
<br /> It.P. .._._.-_--_ ....•- Stan Work Done
<br /> ilepair Wak Dont U Type of Pump -._.__ Sealing wtarfel Cfpth
<br /> Wa!t Doti ruction C7 Welt Diameter
<br /> Tiller Material . ne72h
<br /> Depth
<br /> YVE Of :.t.PTIC%vOhr NEYd INSTAL LAtrON REPAIR!ADOITIUN�JEt.1PUCTION r INo seer's srotem perm.tnal d p,U,c sewer b
<br /> wattabie wthm XA feet.!
<br /> 'tmtatlatiOn w P ae rte: Resident.,l Comme•cisl_.- Other ._. -. N
<br /> Non,ber M kvifro units:..,-_.. Number Of bedrooms:..___
<br /> at!'• / __ Nater tab:e tseptn
<br /> Character of too to a depth of 3'set: 1�-.�Jt���-e3�}- -t+--
<br /> SEPTIC TAN, U Type/Mfg CapactyNo. Compartment! r
<br /> PKC. TREATMENT bLT.CA Method of Disposal
<br /> Diatance to nearest: V/e9 _ Foundeton�_._.__--_ Property Une
<br /> i fACr!ING LINE --- CT O.b length Of Irrtef
<br /> �Tota-length/sirs.--r-a r
<br /> F-ILTFR 3ED'•' 1'X,Dii,tance to neafest! WA !aFuunGalwR-�.-°,�r� Property line --!rel
<br /> LJ
<br /> t, r SEEPAGE PITS I I Seton _.__ -Sirc — Nurnber
<br /> SUMPS L.+ Di+tan:e w nearest: Ve'ee foundeuO,, Property Lens -
<br /> DISPOSAL PONDS ll
<br /> I hereb/crtif 1 that I neve praDared IN%opplKinOn and that the work-o be dOne in"Coed"'ce-1h San Joaqu,n County ordinance f,!Laic taws.an0
<br /> e
<br /> rules and reguisnont of the San Joaquin Cour.tY
<br /> HOrM Owner a GCM•sed ag-ntl tn;nature Cend,as the rGaOM,nQ. •I Certdy that m Ins pertamenca of the work for which thn perrtM if if31led.I snap not
<br /> Horn any pee wn M such m+nnar as to bx'ar*to wblea to woes man's nompensanen caws of C:,,rotroa.•'Conuaetoi s haing or sub-eontwit tlpnature
<br /> certifree the following -I certify that m the h+AOemanee Of the++3rk for wh ch the Port is,eweC .t Spiel employ Oarsor•a s.'bleCt to wwkman's COrnpenaa
<br /> tion tows of Caldante.••
<br /> The spPl,cant miss calf Ia rsyu,red inspettistits.ConyWfen drawi,p on rs.e•se ostia
<br /> � r -- -
<br /> Spra+d X_ ---- Tnla: -_ _�S[�=�r aL-� Data
<br /> 1
<br /> I F!P DEPA ENT USE ONLY
<br /> Date
<br /> App,i:stion
<br /> Accepted by —
<br /> Pit or Grout Inspection tv ____ -- -
<br /> Cam _ Final Irat:.ctirn b•• Dan
<br /> Additioidt.COmnNnIs:
<br /> Apple^_ant - Return all c011tea to, San Joe,utn LOun;y Publ.tc Heal:h
<br /> Services, IIorlrenmental Reeltl. Permit./Ser:ices .
<br /> ' 16Di E. Itate ltca Ave.,-i' 0 B;[ 2th 9, Sto=,ton, CA 95X-1-----T
<br /> RECENED eY DATE I VtMMiTNO.
<br /> TEE AMOUli CUE T AMOUNT fEMtiTED t ��
<br /> INfO _ -
<br /> 6 ' +
<br /> q^c
<br /> v,
<br />
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