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�s <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PtiBLIC HEALTH SERVICES <br /> ENV I RONYENTAL HEALTH III V I S I ON <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EM! S tYE" PROM DATE 122M <br /> (Complete in Triplicate) <br /> Appilcatiot to hereby mAde,to San Joaquin County for a permit to construct and/or Viet+► the work herein described. This <br /> 3 <br /> application is made in eooylianee with San Joaquin County Ordinance No. 519 and 3$62 and the Felts sad Regul,atlona of San j <br /> Joaauip County Public Health Services. rt ✓ I] <br /> Jab Address 1t /I Z1i4w C;sy Z.J r.. Wt SiNvAcirge <br /> Owner's Name <br /> AcYdress gf,-41' Ax,A—C//V � Phone / <br /> 1 <br /> Cortreclor O/" fires � �. l� AW-Z —License N.. <br /> TYPE OF WELL/PUMP: NEVI WELL WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well Q <br /> PUMP INSTALLATIO/N SYSTEM REPAIR 0 OTHER C Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK �/& -SEWER LINES ' DiSPOSAL FLD:!= PROP, LINE � If <br /> FOUNDATION "•AGRICULTURE WELL OTHER WELL ,L. <br /> UM <br /> PITS/SPS :5t:9 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Indvairw 0 Open Sottom 0 Mantacs Dia, of Wall Enlcavation� Dis, of Wall Casirtg <br /> Domaat+clPnvate XGraval Pack 0 Tracy Type of Casing � Specifications�'�' u� <br /> Ptibiic 1 .1 O her C Delta Depth of Grout S!!!! Type of Grout <br /> C.t IrriOaiWn ApWds. Depth fl Eastern* � S dice Sant)nstaised tr., <br /> Repair Work Done 0 Type of Pump s H.P, State Work Done .. <br /> well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Pillar Material A Depth j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L) REPAIR/ADDITION M DESTRUCTION Cl INo septic system permitted if public tower is G, <br /> availabie within 200 feet.) 1,21 <br /> Installation wig Serve: Residence— Commercial,r,,,. Other . 114 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 4 Water table depth 10 <br /> SEPTIC TANK © Typ#]Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Wel Foundation+"--• PrtipMj Lina � <br /> LEACHING LINE C, No. 8 Length of lines ""` _. Total ianith/size t , <br /> FILTER BED n Distance to newest: Wall RbundatiWl.. _ Pioparty.Lino <br /> .l• <br /> SEEPAGE PIT$ i I Depth SireNumber <br /> SUMPS LI Distance to nearest: Wen foundation Y Prop"Line _._ y.,t. Qk-• <br /> DISPOSAL PONDS Ct % ' <br /> I hereby certify that I have prepared thin application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rotas and raia0alions of the San Joanuin County y <br /> Home owner at licensed agent's signature cortifies the foilowing "i cartify that in the performance of the work for which this permit is issued,I"it not <br /> employ any person in such manner as to become subject to'workmsn's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the following:'7 certify that in H»performanca.af the work for which this permit is Issued,I ahaN employ persons subject to woaka+an'a C0MfMVnsa- <br /> tion laws of California." <br /> Tha applicant I ulna cine mpaete drawling on rovory Ll+1,da. <br /> S i nad itis: Data; <br /> ol <br /> FOR 691PARTMENT USE ONL <br /> Application Atoeptad by Data ~�"t At" <br /> Pit or Grout Inspection by net. final Inspection by S���s 2kD. L <br /> Additional Comments: I moi/ t�1�t! 2-12"(0 <br /> Appllcaat - Return a:l coplea tat SAN JOAt30IN COUNTY PUBLIC HEALTH SERVICES ` <br /> ENVIRONMENTAL HEALTH DIVISION PLrRhtIT/S£RVICSS <br /> 445 N SAKI JOAQUItl, P O WX 2009, ST=TON, CA 93201 <br /> IEE AMOUNT DUE A44OUNT AEWTIED C>t AECEIVED lay DATE P$AMIT NO. <br /> NFO yyJ ,,/� fir. CASH <br /> Eel 13.Z1/REV.a.x b3 /J 7&0 � 4LY'•v 7�.J� V <br />