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E APPLICATION FOR PERMIT <br /> SAH JOAQUIN COUNTY PIIBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 �f <br /> P O BOX 2009, STOCKTON, CA 95201 �J LL3 rj <br /> (Complete is Triplicate) <br /> I <br /> Applies 3s hereby Made to Strn Joaquin County for a perttit to construct aad/or inotall the work herein described. This <br /> ' application is Sade in ecowliance with San Joaquin County Ordinance tin. 5k9 find 1862 UAL the Rule* and Regulatlono of San <br /> .� ,fo"uln County Public Health Serwlces. <br /> 64 yLot Star/Acreage <br /> -v_ ur <br /> Job Addrast L <br /> + <br /> Phone 7 r,F- ZS 7`T <br /> . } <br /> Owner's Nsma <br /> �J �2 Address <br /> 10* <br /> r Conn+tlW �' j ___A4Aresi :__"=—r- License 1,1322 R,onC <br /> i TYPE OF WELL/PUMP, NEM.WELL} WELL RFPLACChtENT %7 DESTRUf,TION Li out or Service Well E,1 <br /> i SYSTEM REPAIR �1 OTHER (] monitoring well n 1 <br /> (` PUMP INSTALLATION s7 <br /> {{ DISTAP10E TO NEAREST; SEPTIC TANK —�Fes--- SEWER LINES DISPOSAL F!D. PROP.LINE 3 <br /> C 3 FOUNDATION _AGRICULTURE WELL OTHER WELL- <br /> PROBLEM <br /> 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �f,"��I,gt`Hfuf[FRI ❑QwBosnt <br /> Bottom C]M� ecs Da.of Wan Eauwet Dia.o!WellC <br /> ++ asing 's <br /> pfa�meuk/hweie� *eGravel Pact {1 Tracy Tvpe of Cssuq_ 5peulkatiorts• �'Y rt <br /> �. - Da Type of <br /> I'I Powk f.]0ttvr 11 Dells Depth of Grout S I <br /> r I I IrrlgalPon Ae <br /> '14a_AW*,.Depth '1 Eastern Surface S"tsar *"' <br /> fiepalr Wwk 00" V Tv"of PumtF _ H.P, Slat*Work Done4i+ <br /> {;c•r "'j'I Well Destruttbn O Well Lhsrretsr Sealing Materiali Depth <br /> s <br /> Depth Ifiller Material i Depth <br /> 4.e . ��-"'-----r I'' <br /> rt <br /> O IPTIC WORE. Now 1r*STwtI.AIIOk I I REPAIRrADD111uN I I DESTRUCTION I I INO SONIC•rite+++Permitted N gPbkc sawyer ra <br /> ovaiable within 200 feet.) <br /> Inatomtkm«PN7 wire: Rnaldenca Cwr+rr+er <br /> ic41 Other q <br /> NmplW at bw*j units: Number of tem <br /> 0roos b <br /> •+,�wyN.r 't` 'F; - charsetM of so to•depth of 3 feet:e .: <br /> � Wistar tabu depth +; <br /> SEPTIC TANK 0 TvpeIM10 Cspaeryr No.CoenparbrtertU <br /> rr t .• <br /> PKO,TFIEATMENT PLT.N3 fPubfiod of 0400111,11 . <br /> xx �,�, <br /> J4,„g t4 tri pbesrtu sa nearest: Wen Foundaton Myope„Y Line <br /> „3 �_;_�. LEACHING UNE {:7 No.i Length of tinea T <br /> Total tength/siie <br /> F; '�� 5,1' r 11 fILTEII MED {] oiatsnerl io nearest: Wen Foundation PeopsrtY Line y, <br /> %$drra ti'p: fs ff <br /> YID,�i� ySPr�y rj <br /> SEEPAGE PITS )1 ppth Sus <br /> Number I.y <br /> SUMPS E.t Oatsnea to nes"MI: Wen Foundation Prrstsarty Line 4;r; <br /> r ti,j' 5 DISPOSAL PONOS O � , <br /> I'Ilby osrtilY trey I have peWred this app awork+ion find that the k win xa <br /> be done in co+ice wrtn San Joaquin county adnanee sure laws. <br /> tanand 1', <br /> ( �i pp ” k'# nrfes OWf0immiigns of the San JPaquin CousLy <br /> rte* x.'f c�3C s -Horne owner p Ireensad tlger+t's rgn*w»osrtrfies the fosow+tp:'Y cartih that in the performrncs o}tM worL!p which this ppmie is isawd,3 ti3tW not <br /> emow env PsraW+I”such mens fix to become sublrct to workmen a campensatia't tswa of California.—Con[rselo/s hiring c so w ktrseting n weog, <br /> r� �`�' to nt eMtIM!ttM!oneswir+p:'7[craft'tMl in the WOtmance of the wok for which thisAsrmii is isu-ed.I Wn emPIO De+for+a eubtect W workman•COn+psrrsa- . <br /> ti �n"+q�;yyCyyt. X47 .x ' Iien Wye of Ca111010ie- <br /> R . <br /> Tlta applfrrent } sE 'b pse <br /> ins +itsns.CornWses drawing on rrrww rside. <br /> v?. J�� t �• ` 11 DEPARTMENT 118E ONLY <br /> { t r Appilcetlerl AcCW*d by Oats .? At" <br /> r(,�.i f sta� ".X— nsPac OAKLlf l <br /> �1�rfRxrs' PN Or CVV Insp�rtto• pt/r Firssl I tion DvAr <br /> G_ <br /> I4 n {*a* Addhkw4i Comrnente: ?i g <br /> irtl�r 1 Appl3ea*t <br /> � Hetero a17. capias to, Baa Joaquin Count? Public He <br /> k , d�A' Service*. mvironawntal Health P'eralti5ervlees 3 <br /> FAseltae Ave., P O Boa 2009. Stockton. CA 95201 . <br /> FIE AMO%MT Dug AMOUNT RFatITYID CK I RECIrVED by DATI HRAgT'►.J. ; <br /> , �V•i t )MIO CASPI <br /> * s k4 <br /> y' <br /> fir <br /> '���i,41 <br /> t���� �ti. .'�+1>w!'•�b4kn.s:nnv't5es�. - -T#��..f <br /> i <br /> �' 1p.irY-11n." <br /> 'ra <br /> rY. <br />