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APPLICATION FOR PERMIT <br /> sm JOAQUIN COUNTY.PUBLIC HIMLTH SBH•m=8 <br /> WIVIRCOMENTAL HEALTH DIVISI4NI <br /> 1601 B. HAZSLTON AVE. , PHONE (209)468-3420 <br /> 0 P O BOX 2009, STOCRT(I, CA 95202 <br /> e PSI'RP'TZT RSPIRB4 tyteeR 8iasn*R nn•r•ts Aoe:,;w <br /> (Complete in Triplicate). <br /> Ayplication is laroby ,endo-to 8nn 4oaquin County fora ' <br /> t�y].1cat1o3 io t_:de III permdt to construct nad/or inotall the York herein described. Thin <br /> co`:ZPUnco trith•Ban Joaquin County Ordinance po. 549 and 1862 and the Ru100 and Regulation* of Ban <br /> Jonquia County Public Health SOrbleeo. <br /> r <br /> . <br /> Job Addtoeo •r� <br /> +(. City Tot Size/Acreage <br /> 4 Ownceo Name K-�tf� / '�1� ddron r <br /> c��^ Phone <br /> Contraclbt"' Address- "-• License No. Jo�J6T �a� t <br /> `-TYPE OF WELL/PUMP: fNEW WELL O WELL REPLACEMENT C] OESTRUCT1014-0 Out of <br /> Service Well G] <br /> "*. PUMP INSTALLATION O SYSTEM REPXIR ❑ OTHER•"O Mmitoring Wali <br /> OIS-fA�NCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -, % PROP. LINE <br /> w FOUNDATION AGRICULTURE•WEELL OTHER WELL PITS/SUMPS <br /> I^ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F ' <br /> 0 lnduatrtal O Opon Bottom O Manteca /Dia. of Web Exccvation Dia.of Wca Caning <br /> 0 Dorrinetie/Private . 0 Gravet.Peck ❑ Tracy Type of Casing- <br /> a y f'1 Public f"1 Othor n Deb 1%' j Depth of Grout Seal Typo of Groutsr•-,--• ,, F- <br /> 1•I trrigtltdai"' _.Approx:••Oopth t I Eaatrmt� ♦ rS <br /> Su Scat inatcUod by <br /> -.1 Ra cit Work Dow U T r` i- ' � <br /> Ypo�.Pump ;s H_P. t - Stato Work Dodo Z i <br /> 4'Wee Demuction O Wert Oisrmator 8colitz nitorial 8 1" <br /> r4 O <br /> O=pth r Fi13AraC3iL`,rlal r-Doythi - <br /> 'l�"!'•" `TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1• REPAIR/ADDITION DESTRUCTION t I INo r <br /> •M :s ".' j avis wdtltiri 200 foot.l A pubkc sewOris <br /> Inaic tion win c,'xvo:• Ronidonab-dk, m <br /> Comercic-i tChu <br /> -+�-.s'_ �' l 'E: _• <br /> s Numbs of*vim Winn6-/-- - Number <br /> r t Cherett`r Of CW to odoth of 3 r <br /> 1f-..at: Water ttbl*depth <br /> (." SEPTIC TAAICL. ❑ .Typo/AAfg ' ' `�'•Capacity- ASO. Cornpt rtmone; +� ; <br /> %,PtCG!TREATMSNT PLT..❑ <br /> 7 E. Lazthod of OsEpoeat r <br /> to ranraat: Wcl1 t Foundation "pr •- <br /> 'r LEACHING vNi"r,&'No.•G Length of Or= Total bngtft/size ^ 3 <br /> FILTER SED {J Distance to nae ent: '.Wea• ' r Foundation +�� � P rOpCrtY Rlrq <br /> `.20',•,r � --•�a�-•-- . <br /> r A : <br /> SEEPAGE PITS i i' Dcpth •► i irs' 2 Number t• `' <br /> a <br /> SUMPS Ll Ointaneo to n=76: WcR Foundations Property <br /> DISPOSAL PONDS . . ° _ .7.. <br /> f tWcby ccnify that 1 lave praparcd this appftcdan andthat tho work win be dons in accordance with San Joaquin County ordine tcos,steto L^wo,and <br /> ruts and regulations of tho San Joaquin-Bounty c' ;. • `• <br /> Homo ownar or kcriecd eoonta toaeturo cwtifis tho foaavving:''t certify that in the psrformanca of lite work for which this potmit is ,t chap not <br /> ' y f cvcfi rrgnt>rr q t0 b°bcv=e4bi=t0-W0rkm0n•a COmponeation taws of Cclifomia."Contractor's hiring of autrcontmeting tignatum <br /> cend=tho fotlowing:"1 certify that in tho of tho work for,which this parmit ra bwod.I zW employ portans iwbpsct to workman's componso- <br /> tion bvva of Cr fornio." !" ra <br /> Tho cppiccnt for "" .4- <br /> ^cfion=. Comptoto'bra%4h-n on roverno sido. , <br /> Signer X "d''.--,—,i" Tk19 + /1�..-rtis - E ' <br /> }, f —��_ Dote: �/ <br /> T' � c <br /> �-•� FOR DEPARU460T USC ONLY � { <br /> Apptkotion Acccptod by ]tom Z� -•'�_ Otto f• �(* Arm 3 , <br /> P --. _— c' atm <br /> ft or Grout kt coon by Onto Fine!Inspection <br /> +��---•--',,...,ter---•-- <br /> hdditiond Canrrgrtta: ► '� <br /> Applicant - >?atma all..-caPloa.toss.&sn_aoagu3a-Cotnty.�."�ric33eC1�•'" "' - •s ._._.� ... - -r .� <br /> Sorvioco, 12ttvin�tal Health Pbrcit/$orvicea <br /> 16Q1 B. Aat:altoa uo.. P 0 Sox 2009, Stockton, CA 95201 <br /> tFWED 1.EE AtYALiN/T�O/RIE AMOLWCT REII�T�T7ED CASH RECEIVED OY DATE �sPEgrntR'1v0. <br /> .Eli ty2I1nEN.►isa j� •l•'10 1 [ I�SDv Z.�g f S��• �f / f/t <br /> EM 16t:� <br />