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<br /> 7� APPLICATION FOR PERMIT
<br /> t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION
<br /> r� SrJ y 445 N SAN JOAQUIN, PHONE (209)468-3420
<br /> �t ai P O BOX 2009 STOCKTON CA 95201
<br /> .
<br /> �r ° ,��9?:'•, pERYIT E%FIRES 1 YEAR FROM DATE IS�$jj "
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<br /> (Complete in Triplicate)
<br /> Apyllcatioo in hereby madeom. Ran Joaquin County for a Permit to construct and/or Inst4,11 the •ror\ herein described.
<br /> 1T1e '
<br /> KI°t;i r m spV11catioo Is made in cosi with Lon Juquln County Ord{nnnca No. 549 and I862 and the Rules sad Regulations of G-n
<br /> FC 4✓Sia ,`y - Joyuin County Public Health Mrwicae.
<br /> �"Trv�'r, Ykt` '714` 5 �... /�,J/ �• tLr.•t) Co lot Size/Acreage
<br /> ? .y t/Job Andreas f
<br /> tl"vr l .I/•'._.N /� /•- '.45�•>_ �� Pfuzrw �
<br /> �6wrWr-s Nams'Ij(tz.N .�` _Le r Address .
<br /> + vti.
<br /> ,�N /Q` �1 _ License No. Phone
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<br /> � Conlraclor -_Address__
<br /> T ✓ TYPE OF WELL/PUMP: NEW WELL O WELL FEPLACEMEN7 1 DESTRUCTION Ll of beriee Well
<br /> PUMP INSTALLATION SYSTEM,REPAI9 C - OTHER O_, Monitoring Well [3f
<br /> �. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.__,,PROP.LINE
<br /> FOUNDATION AGRICULTURE WELL OTHCR WELL PITS/SUMPS _
<br /> INTEt:DFD USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_
<br /> ;�F F',,
<br /> Cl InJusvial .- 0 Open Bonorn G Maniacs ,Dia, of Wall EmuvsGo„ Cie.of Wall CNsirp
<br /> . DameuK/Privet• O Gravel Pack -1 Tracy Type of Cesing_ _ SpeNlkatbn.
<br /> I'I P,6k . . n M
<br /> Other - n Delta.. eth of Grout Seal 'Type of Gra.t
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<br /> Appro-. Depth. I I Eastern ^� Surface Sart Imulled by
<br /> Rspelr Wor■ Done L3 , Type of Pump H.P. Cute Wort Dona_ k
<br /> mid!nwtion LWet!Diameter 8salirrt.Material Deytlt y
<br /> Dpth yiller MAiturial i Depth f .
<br /> vPE OF SEPT.0 WORK: NEW,INSTAL TION .REPAIR/ADOITION I I DESTRUCTION I I (No septic system Perm ued It p1+Wt srww w (/1
<br /> avadabN within 200 foot.1 v
<br /> 5 1 IrvtsKatWn w11 so" R /ons,__ Coen rterca1 OtMr $
<br /> mber of kving unry;_!_, NungW of bodroom," n
<br /> ` L.O 1 J
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<br /> Character:of ao�to•11s0t11 0l 3 feet: 1HatM tat"depth ,
<br /> SEPTIC TANK. - .� Type/Alf, ^_ off�r c Crpacily_ No. C."...
<br /> r PKO,TREATMENT PtT / Aisthod of�jOi�apo�sM h
<br /> r , Disti�ce to naaretl:. WeN.1 d Foundation_ S Progeny Lino
<br /> F
<br /> :EACHtNG L'INE' No. i Length o"lama Z' _-Total length/azo-
<br /> J T
<br /> < r Foundation �Q Property LimeS� r'
<br /> ,. FIL,ER RED, C Distance to nea,mv
<br /> Wall _ T7
<br /> YLyY+v
<br /> V°
<br /> r i SEEPAGE PITS Size
<br /> `c P �, t�• rSU1kP3 : :, LI Qatar,ce w nearest' W44 /)�. Foundation Property Law... _.../✓
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<br /> POl DS `O
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<br /> heroby certify that I have-prepared tMs appiicat—and Ihat tts work wiil be done in accordance with Sal,Joaquin County 0,` & csf, ants' Iva end
<br /> rptrlatiom M the San.Joaquin County -
<br /> HfomdPwtw cw kenNd apeM's trpnature 04nific3 the following."I cart!}y thr+In the AaAormance of the work fa whkh thn perm w resume,I"ha r-11
<br /> M such norw+ef.so tc t+soomA subject to workman's compensation Uwe of Cslifofria.':Contractor's hi or WDcontr1Ctinp W&ANUO 3 a
<br /> employ sty Psnen
<br /> A .vete r 6Wjf sa It.foNow,nq I evafy,that In the psformanca of the work for which this psrmk is iaued,I►hall:employ Demons wbfect to workneNff
<br /> �htrt fo a zu o� w' tbn fawe
<br /> of
<br /> red lana Corr.FJets d+tw+ng or evKsafid+..
<br /> 4,
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<br /> t��X
<br /> R DEPARTMENT USF ONLY
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<br /> vi AppYClt6n Accwtod by 1.� --="t.-- "'�= `��•+w Dalo.�L�.L +Y At" `*
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<br /> + ; - Date ..� Final lnirpoction by IL= f •Dt»
<br /> fKt w Crsut Inspoc6o.n by -- ��'�' _
<br /> r �Tz ' � Addlrarvl Crxtxri9nxte
<br /> Aypi ico t! RmtUrn All-copies to:' San Joaquin CouhtyLPublir. Heal ih Services -
<br /> "talht Environ"ntal.Nealth Permit/service.:
<br /> 445 ff.San Joaquin, P 0 Lox 2009. S•kn, CA 95201
<br /> yFit,; AMOUNT 0t/E AMOUNT 11ELtITT ED CASH If[CFIYEL`gY DATE ►t11MR'NO _
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<br /> JA
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<br /> ti y t i ,o�, 3ra 4k K��w.. 461.'±NPl+�" ' , kv,e,'ti�ir•�Y-;-S.i4a
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