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<br /> APPLICATION FOR PEEWIT
<br /> r ,Eq.,rs �r ly•
<br /> SAN JOAQUIN COUNTY PUBLIC BEALT11 SERVICES
<br /> r• �/ ENVIRONMENTAL ILEALTB DIVISION
<br /> � 1 ;_ 1601 E. BA'LELTON AVE. PBOPHONE' (2.09)468-3420(2.09)468-3420 -c I
<br /> " f«!{ P U BOR '1009, STOCKTON, CA 95201 � °4 y* '��V,
<br /> t .. PERMIT EXPIRES 1 YEAR FRUtl DATB ISSUER tx r1a.l r Y
<br /> (Complete in Triplicate)
<br /> 'STI.
<br /> rein
<br /> Ayyacatioo Is hereby mad e.to San Joaquin County for a j�atit to construct and/or 1nsta.Ll the work hed '3e6ueeerlbed.
<br /> application is xi in compliance with San Joaquin county Ordinance No. 549 and 1862 and the Rules and degvlationa of San
<br /> Joaquin County Public Bealth Servlcos. ,�� Rte
<br /> 4.x :
<br /> 7 // ��.-�JC'�t.l l/�Q' t alze/Acreage
<br /> 3S-
<br /> OILY
<br /> Job Address
<br /> Address All-1--�P __ Phone .J.
<br /> C net's Name,., - y
<br /> License No. Phone
<br /> •:- � o >ti4a
<br /> Conliactor Ye _---Address
<br /> � _
<br /> WELL REPLACEMENT l7 DESTRUCTION C O'ut cr Seryice Well u
<br /> TYPE OF WELL/PUMP: NEW WELL O Monitcring well C]
<br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O
<br /> it SEWER LINES - DISPOSAL FLO. PROP.LINE
<br /> DISTANCE TO NEAREST' SEPTI_TANK OTHER VfELI PITS/SUMPS
<br /> FOUNDATION ._.— AGRICULTURE WELL
<br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> Dia.of Wail Casing >? !U •
<br /> L1 Industr al O Open Bottom C Manteca D,a.of Well EaelvatiOn Speubcahons -- i
<br /> [I QprtleetrC/Private C Gravel Pack ❑Tracy Type of Casing rat
<br /> s !7 OIMr a Delta Depth of Glout Seal _ type 01 Grout !3, � u.
<br /> I I Pufc :
<br /> M
<br /> 1 I Imilaiv n { APrwoa. Depth t I Easton Surlacs 50 41 Inlrauwd by
<br /> uta Work Done
<br /> Repan Wort'Dore U Type of Pump
<br /> H.P. --•— y, �A�
<br /> Seal ina Material E Depth : .
<br /> Wee Destruct on O Won D,artetat * L L
<br /> (. y111er Material epth
<br /> Depth
<br /> x TYPE OF SEPTIC WtiHK: NtW INSTALLATION: , HEPAIRIADDITION I DESTRUCTION I I INo seol1c syslor*,{xrmntan J public fewer o
<br /> evadable withm 200 loet.l 7
<br /> All,
<br /> _ c s
<br /> Insto4stfon wtq serve F10"Onlce_ Conwner,:ial_ Other t 4
<br /> Number of room,_ - 4
<br /> Number of tivwv units wear uDta depth -
<br /> �,p(p�gj No.Compartmanu v�
<br /> Cnarsctea "' to a depth of 3 loel:=r}=Nj-- ✓� Capac ty_J fv
<br /> k SEPTIC TAN14' Type+Mlg C
<br /> Method of O,spossl
<br /> Pli TREATMENT PLT.C t SO/ 7C"i I�aY
<br /> n
<br /> Distance to nearest: Well G Y Foundalwn °rot arty Line
<br /> f _
<br /> ti - C�N •& Ih of Laos S3 � Total tangth/sirs
<br /> LEACHING LINE ,
<br /> mss_,
<br /> •t""tF. �FIITEM,BEO O Diraanu to nearest; "
<br /> Wait �S/ FOvndatan��_ Property line '`
<br /> 1
<br /> Y�. x,
<br /> f"v bet'
<br /> i f Sue Number
<br /> rrK SEEPAGE PETS Depth pS .L
<br /> �l / I_ Pruperiy Lira,
<br /> rt' SUMPS ..,t; 1:1 •Distance to nowesC Welt /7,/ rougdatan. s,k
<br /> 9t 11 DISPOSAL PONDS
<br /> I herby candy that I have pep+red thisepplicatHm and taut M work wdl W done In+ccutdanca-1h San Joaquin county ordm:anCos,sate
<br /> runts and regulatwro of the San Joaqui., County
<br /> Name owner co Mcansad•goo's"nature Certifies the tottow o,g "I cartdy that to the performance OfC4ce of the work for wn,cn this permit is issued,t 9na It not
<br /> ernooy any person in such manner as to Lacorne aibpct to workman's componis non Laws of CaulI"ll
<br /> Contractor'sPerhump or su D-contracting's c signature
<br /> rat' cendlas the losowrng:'•I Comfy trot tai the partormance0f rhe work 101"Inch this perrrut n awed,I shall employ Persons wbpct to vvakmart s compMaa-
<br /> 1t lion yws ofrCslitornla."
<br /> r r tans.Cnx'nplen-d.ewm+g on reverse sr lv- Z u'
<br /> TM spOMCaP( sl cab for ear ngyKad y►Pec
<br /> Title: �1�
<br /> •f .� FOR DEPARTMENT U'E ONLY {
<br /> t
<br /> Dat.
<br /> ion Acceptod DY
<br /> Pr
<br /> Pit tbr Grout ini pactbn Dy -\, 'tom `i-J Date J _ Final Inspecun
<br /> oDy� l i -- Data ^ry
<br /> t Addhforel Comments: '" !
<br /> Applicant - Return all copies to: San Joiquln County Public Health
<br /> -
<br /> Seryl
<br /> Health Permit/Service,
<br /> 1601 E_Raseltoo Ave., P 0 Box 2009. Stockton. CA 95201
<br /> FEE AMOUNT DUE AMOUNT REMITTED CAS"t RECEIVED Ey DATE PEfiMli,v7 .�a
<br /> INFO
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