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APPLICATION FOR PERMIT <br /> saw SAII JOAQUIN COUNTY PUBLIC REALTH SERVICES <br /> ENVIRcgaW AL RE PHIU DIVISION LNE (209)468-3420 <br /> '.601 E. RAZELTON AVE. , <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PRNIT E7PIRES 1 2^•.AH_pB4,1LPrTTLLS. <br /> (Complete in Triplicate) <br /> Appllutlon Eahereby rde to Sax, Joaquin County for a Permit to construct ax,dicr Install tfc work berein described. Th-'Z— application la able in ca.pllaoce vL.h ran n <br /> Joaquin County OrdInsce Ao. SLS and 1862 end the Role- —4 PcguL hone or Sen <br /> Jcapwio CPunty Publle Bealt�Bervice.. r <br /> ! Llry `'y l.ot 51 to/AcreaKc <br /> _oD Address l E y— <br /> y, Owrwi s Name_a__`.TZ'—"`rte 7,� <br /> Contractor <br /> �1 /%/A f nkU G4J]aSs h�l•s-1r '+Y-L�ctnse No t/,� .Phone <br /> TYPE OF WELL P P' NEW WILL ❑ WELL REPLACEMfhI I Wall' LI <br /> DESTRUCTION C Our Monist 1m Well. (; <br /> PUMP INSTALLAYION O SYSTEM REPAIR C OTHER ❑ <br /> 7� DISPOSAL FLD.__ PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PITS/SUMPS <br /> FOUNDATION �__ AGRICULTURE WELL __ OTHER WELL _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Du.01 Wish Casing <br /> Ll Induaw W E Open eouom Ci Mameca Dug.of Wall Escevation D.,.1 atish <br /> — Type o1 Casing <br /> f 1 Domaetic/Pnwle O Gravel Pack ❑Tracy Cepih of Grum Seat <br /> of Grout­— <br /> I'I Public I"1 01", fl Delta <br /> I Irrhlalgn __Appem.Depth 1 1 East.,. Surface Seal Installed by <br /> H.P. _ Stnr Work Done_ <br /> Repair Work Oune Ll Type of Pump ---/Sea11n8 M"r1a1 i Depth r\/T <br /> Well Destruction ❑ Wall Diameter 1 <br /> Depth Filler IYterial i Depth --I <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION 1 REPAIR/AOOITION I I DESTRUCTION 1 ±NsilsbDelwthin 2UlIleaA�f� <br /> .ed it puphc s+wer Is 1. <br /> Intima tion em verve: Residence Com e"i'l_ OIMr <br /> Numtw of kvvlg unite: Number of bedroom• —Water tank b:pCrunchier of a0E to a depth of O feet:SEPTIC TANK O Type/M!p__{ — Capacity ^ No.Cotnpert—APKG.TREATMENT PLT.❑ Metnod of D' ro— Distance to rlsa.0 well.�_ Foundation�` L_ PropanY LineTotal lang1W,urf,LEACHING LINE Ll No.&Length of linea a <br /> FILTER BED ❑ onain c. Pro rt to merest Way aI L D FogrWnion if L.— Pa Y Line 1- <br /> - _ <br /> �S:re__ Numner 37 <br /> �.p�— <br /> SEEPAGE PITS 1 I Dist n PromM Lim <br /> Slump LI Foundation r�� <br /> LI DLaunp to menet: WNIµ�DISPOSAL PONDS PONDS ❑ <br /> .. 1 hereby cony that 1 Mw,papered this OPPlkatiotl and mal]he work will be done in accordance with San Joaquin county oldinances.state Laws,and <br /> rule.and reguktwnl of the San Joaquin Coati I shall 001 <br /> Home owner or u.n.aed agent'.dgnatun canHks m.Iollowmg: 'I cmtifl that in iM paAormano of tie work It,which this Permit is Issued, <br /> empbY any Person in such rmnner as to naLCrna..bpct to workman's compansabun Laws of Cslllornla."Contract.,,.hil:ng c I auPconuacbng ugnaNre <br /> smoun,any <br /> Perso i in "I h merertify That in EM performance of me work for which this permit is issued.I Nall smploY PO nm ruble.t to workman's eon:oan.a <br /> Carnf <br /> jogd <br /> tion Laws of Colifon"13 <br /> e� au Brewin on reverse side. <br /> TM epplicW most cell for NI requuepsi nspenions.Corr�W D <br /> '/ <br /> 5iprla0 A- .�- -� <br /> Gate: _ <br /> J hOR DEPARTMENT USF.ONLY 3 <br /> — Dan ane <br /> Application Accepted by <br /> i pQ,gagroorr tion by - Data Fiml In.peClion by Dete % <br /> neper �—_ <br /> Cn v <br /> Additioml Lolttrmnta: <br /> sea <br /> Aapitcaut - Aaeuro ell copies to: S to. .. Mo County Health Persat/Services <br /> 1601 E. Mselton Ave., P 0 Boa 2009. Stockton, CA 95201 <br /> NEE- AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BYEDA�TlIEP.MII NO. <br /> FG <br /> asse <br /> fM 147/ \ <br /> L <br />