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_ v � <br /> APPLICATION FOR PEMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95202 <br /> °EFllIT E%PIRES 1 Y all FROM DAT ISSujm, <br /> _ (Complete in Triplicate) <br /> ellcatloa is hereby ode to Bao J" Co. <br /> Ru.e Coty for a pereat tc construct and/or 1n.u11 the -,.,itLeraln 4...rlbsd. Thi. <br /> '.'➢lleatloo Se rde Sa coli vith Se. JoaRuln County Ordlnance No. 519 and 1062 and the Bulu lod Aqulstlone of San <br /> Jet11tt1D County Puella JHealth BemcT.. q <br /> Job.AMresa �Yb7 Y SO��i L: S _ City Lot Ylle/Acrew/lr <br /> lHt --✓_-� f— a_�pFOwner's NPhonePtiRA' <br /> _ <br /> Convaua dd41a � - men It No�� Pnonep—z <br /> TVPE Of W LL/P' MP: NEW ELL ❑ WELL hFPLACEMENT r1 DESTRUCTION L1 Out of Serrlce Well <br /> PUMP INSTALLATION ❑ SYST;M REPAIR ❑ OTHER ❑ NoniterinE fell f] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION__ AGRICULTURE WELL _ _ OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑IMuatnum ❑Open Bonom ❑Manteca Db.of Wall Eac.wh,'n 04.of Wag Caging <br /> Cl DornsNk/PrNate ❑G,"Peck ❑Tracy Type of Cuing-__ Specilfcationa <br /> ('I Public 17.1 OIMI El Delta Depth of Grout Bad TYW of Grovt� <br /> _ 1 I Inpelgn _APpoa.Depth I I Efstam Burl."Seal Inf41wd b, <br /> MaPW Wall DaM ❑ Type of►unit N.P. Sup Won.Done <br /> Well DeeNKibn O WN Diaflwts, Sealio/ IYterlal E Depth O <br /> Depth_ / Plll r Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ <br /> ADDITION DESTRUCTION I I IN'.uo a/nom peevlinad it public sower 4 <br /> available w,Ihj,i VID tot.) <br /> Installation will Maw: RYlfl e L Con ro'clal_ Gillet <br /> Nur ON of Wkq fruits:yINurMsr of hednooma <br /> Chwww of all M a depth of i feet: Water tat-t depth, r <br /> SEPTIC TANK. O Tyq/Mfg IL C PalY -D No.Comm <br /> partents �/1 <br /> PKG.TRLATMFINT PLT.❑ ..N Metlnd of Disposal <br /> Oletfn"to naereat: Wall u <br /> Fondation � PlopanY Line Z. <br /> LEACHING LINE ❑ No.E Lonfllh of lino 7 �O Taul langtnhia .R.D 10 <br /> FILTER SED ❑ D4tw..A to nevnC v4vm jz;'5 _ Famo.imn 1p 2_ Pmp&AY Line l �a ' <br /> SEEPAGE PITS II Oaf Si" <br /> In Jd tNumber v — <br /> SUMPS LI Distant,[o IlaNeet: WNIA� Founnation �t 5r� Property Link <br /> DISPOSAL PONDS ❑ ' Y'T <br /> I herabY Wily that I haw yropared this application and that 1M work will M Som in accordance with San Joaquin county oraoan"A Nate laws,and <br /> N"aIle NOUBMine ouln of tie Sen JosCounty 1 <br /> None atwer Or Starved agm9 fthillWa condi"IM following;"I comfy:hal In the pedormence of the work for which this permit is swad.I"I ml <br /> 0 Ocy"MiNs n kt Such Itteretar sa W become subject to workman's compensation Owe of Cofonnte.-Con'"lo/s hNot;or Mao-chovscbng tkgnawn, <br /> callifilk <br /> tiCe feNef o f I chatty that in the parfamNKpermituW <br /> a of the work for which Ws IS iw ,I Shal emPIOV Paw a <br /> of cawaffH2.11 <br /> Parsons subject workmen's cnpeno. <br /> TM fppNeAnl rJg1 1 Iw »2uk t n Actions.Compote tewing on rewrsa aide, • <br /> ` R DEPANTMEN7 USE ONLY <br /> AplStlllbN AoepaM bV <br /> _ �a G»ut Irllpettgn by lL��ef�- +ate 1.d��cFmN Inspection by����4/� Det�y,.7��L <br /> AtldnlaW Comnw,u: <br /> Applicant - Saturn all "Plea to: Sora Joaaule County Public Health services Mu <br /> luvll..m.t.1 Health Pernit/Sarvlcee 1 - <br /> aah N Bao Joaquin, P 0 Boa 2008, Stko, GA 95201 <br /> FEE AMOUNT W! AMWNT AEMITTfO K RFC[IVfJ my DATE PERMIT NO. <br /> INFO MDASH <br /> tat // `/salAav I,.0-SAi <br /> tN,f <br />