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<br /> ! APPLICATION FOR PERMIT
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ' { ENVIRONMENTAL HEALTH DIVISION
<br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420
<br /> P 0 BOX 2009, STOCKTON, CA 95201 �
<br /> iT TxpIRBS 1 YEAR FgOM DA1'fi IS9 fiD
<br /> (Complete in Triplicate)
<br /> *in described. This
<br /> by sada to gat) 1oAQu1n Countfor • pe rmlt to construct rnA/or Snsu11 tM work her
<br /> application is stare in Coagllanoe with flan Joaquin County Ordinance No. 549 and 1862 err! the Pules and Regulations of Ban
<br /> Application is here
<br /> Joaquin County Public Health dervices. r
<br /> Lot SirIe/Acreago
<br /> ` t "1 City
<br /> `..�( Job Address
<br /> ' DL1L5.2,I1Z! Phone .
<br /> Address �1Vv
<br /> I Owner's Nan•+a /_ '7
<br /> Address �a-� License NoS Z C�Z G Phone.J r
<br /> ConUatt DESTRUCTION ❑Out of 8arvice Well
<br /> ( TYPE OF WELLlVUMP: NEW WELL ❑ WELL REPLACEMENT (.] µonitorina Vell ❑
<br /> SYSTEM REPAIR ❑ OTHER ❑
<br /> PUMP INSTALLATION ❑ PROP. LINE
<br /> _ SEWER LINES DISPOSAL FLD.
<br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS
<br /> FOUNDATION AGRICULTURE WELL 1
<br /> v TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of WON Casing i
<br /> INTENDED USE �_ -- Dia of Wall Excavation ta)
<br /> * t- 0 Industrial. ❑Open Bottom ❑ Mane,ca Spetilkatrons
<br /> Type of Cesing.�.�.---- (7
<br /> n Dorneatrc/Private O GravN Pack ❑Tracy Type o1 Grouter— YV
<br /> Det th of Grout Seal
<br /> Publlc (I Other n Delta Surface Saul installed by 6
<br /> tr=�stbn �_
<br /> Approx. Depth I I Eastern Sue,Work Done_
<br /> .s,t H.P..—_
<br /> Rr.paur Work Dont U Type of Pump BeuStt� Material 8 Depth
<br /> Wah Destruction Q Well Diameter
<br /> (leer gl/terial i Depth
<br /> Depth 1 rblic rawer is
<br /> r available within 200 feel.!
<br /> TYPE OF SEPTIC WORK. NFW INSTALIrTION i l EPAIR .DDITION CESTRUCTION I INo septic aVaem permitted f Pr
<br /> - Other -
<br /> n +•� ,R r�, + Inatfimnon will servo: Residence Commercial
<br /> rpt ,� t '•� } �_" Number of rooms Wales ubk depth , to h'•
<br /> T i depth of 9 PML•
<br /> SNunther,ol Nvinp units .
<br /> s r I arwer 01 soil to a - 7e�"---� CaPaCItY-_ No.COmpartrrwnts
<br /> '.7fSEPTiCTANK ❑ TyDeAlfp __--- Method of Obpossl
<br /> PKG. TREATMENT PLT.O Property Line
<br /> y. p Foundation
<br /> :v,�J •;. ti+ „tom'-
<br /> Clot
<br /> to neuett: Wetl
<br /> ' r - - - Total lengthlsi:e_, X X
<br /> r �i Frvt r No.B Length h of lines P!oWrtY Llne
<br /> �Fou`nd#60n��Olatanee to nearest: Well_fi
<br /> g FILTER BCO --
<br /> h ..
<br /> Number
<br /> �--
<br /> E Depth -Site -IM
<br /> SEEPAGE PITS Foundation Property!
<br /> ySy4�a SUMPS LI Distance to
<br /> nearest: Well_
<br /> .ii, wy-xK�, CISPOSAL PONDS - ❑ " -
<br /> = I herCDy certify the!I had!prepared this application and that the work will be done in accordance vnlh San Joequln county ordinances, Blau laws, ar*i
<br /> raWitstions of the San Joaquin county following:l•, Y'
<br /> rlormanu of the work for which this tea
<br /> rmit is issued,I ah1N r,ot
<br /> 'Home Owner a licensed at;ant's algnatu:a Certifies tM O workmen i„comPansat'oatinIhn,l+vn of Cnlilornia.”Contractor's I+irinq or aultCo^t!ettinp apnarvre
<br /> ison$subject to workman 6 Co 00"-se
<br /> r• j3'..,»�Y ampidY.any person In au&%"nM/as to become subject
<br /> 1 shall amDbY W +
<br /> a�r rn tarhf sa the loNowvW 'I certify that in the performance of the wor5;for which tnii permltfs issued.
<br /> ( elo+ uiws of Calilanb'.._. _
<br /> -:'Th*81, r, .tau tor. r it inapeetbns, Comoote drawing on reverse si /
<br /> \ pats' -
<br /> tiff.fd�• - �:, Title: ��
<br /> .srw yLL
<br /> • FOR DEPARTMENT USE ONLY,,
<br /> Dat ` - Ansa __... y:
<br /> ►t+Wkaiton Accepted bV Dat / ��[
<br /> y5. �t'Sr C 0ste_---- FinP hapectbn by '- . P
<br /> e W ,z'r. Ptt cr 6!out Irypectbn by .. ''�
<br /> v 1t A
<br /> Additto!ial Commenu: r�bllc Health r
<br /> Appllosot Return .11 cviYisa to,, San CerioaC;l�v°cesir'�n`a1 Kea�th Perait/94rvices
<br /> 1601 Z.-AAselton.Ave.. P 01tox.2009. BLockton, CA 95201
<br /> DATE? 1ERMIT NO
<br /> Y yrtn ` RECEIVED by-
<br /> CASH
<br /> AMOUNT DUE
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