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APPLICArT,ION FOR pbf?13IT <br /> - Ff r .fir r~r.iry <br /> SAN JOAQUIN COUNTX P6;Y IC EEA TH SERVICES <br /> ENVIRbxU NTA1"," ALTH DIVISION <br /> P O BOX- 2.000, UOCXTON-, CA 95201 <br /> ('209) 4168- S440 , <br /> ,. <br /> ' <br /> (Complete,-In Tripllcute) <br /> �111artcs <br /> ltcetiva le tea.debin 00 CGto in <br /> vith. <br /> Joaquin County los• a psrm36 Lo Construct *nd/or tnetAll thu work bereln described. Thle <br /> "A i"quin County Ordinance No. 549 and 1862 and the Rules sad Regulations of Sun <br /> gvla County Public Nealth Services. <br /> City Los Htse/Acreage <br /> sari Name Address J •�•yQx �� l J <br /> f7 / Phone 1 <br /> -57 <br /> r <br /> tractor ,� Address o,jBOX /GZr't8� 'G Gi <br /> ly <br /> Lrcense no.7Q{� _ Phont <br /> E OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ put of Scrvicc w <br /> PUMP INSTALLATION O o1i ❑ <br /> SYSTEM REPAIR �^, OTHER Or No ttoring well <br /> r :rvCE 70 NEAREST. SEPTIC TANK SEWER LINES _/Ct ' SOff' Prbl4175 <br /> DISPOSAL FLDN/,d_ PROP. LINE _6:1 <br /> FOUNDATION _ AGRICULTURE WELL �1/�4 OTHER WELL -LO-L- PITS/SUMPS ,yam <br /> rrTit"OEO USE TYPE OF WELL PROALEM AREA CONSTRUCTION SPECIFICATIONS <br /> laultr'al Ca Open Bottom O Manteca Dia, of Weil Excavation <br />>omeluuPrivat, -.-.�-- Dia. Ol Well Casing <br /> Cl Gravel Pack n Tracy I TYAe of Casing o <br />„prc Spacilicaltons ,�"�_ <br /> hhother ❑ Delta Dept, of Grout Seal L'��� <br />,.Vj&.On ��! A - sa..YJ_fAlf...._._. Typo o! Growl- .- <br /> pprox. Dsplh p Eastarn Surlac'a Seel Instatlud ov ,.� <br /> air Wort Done U Type of Pump H.P. <br /> Oertruction S141e Work DOM _ <br /> O 1N*U Dlametsr �•��. 8ealirtr< liatsrial i Otpth <br /> Depth 1ri11er Itaterla1.4 Depth <br /> E OF SEPTIC WORK; NEW-INSTALLATION IU REPAIR1A OtTION C1 DESTRUCTION G iNv septic syslnm permilteo it public Wwar u <br />,rte will serve Residence i available within'200 foetJ <br /> • Commercial,� Other , <br /> living units; Number of bedrooms =� f <br /> r1114cler of soil 10 a depth of 0 feet; - <br /> TIC TANK O Type/Mfg -----Water table dspth �_ <br /> i. <br /> TAEATMENT PLT, CT r Capacily_.__4.__ No. Compertrrents <br /> Distance to r+earssl: Well •''°� Fountlet'on Method of Disposel <br /> ._.,_ Progeny Lind _ <br /> CHING LINE C1 No. b Length of lines 7. <br />"EA BEDfa Distance to nosrest:' Wall --' Total longth/size <br /> 1 ';Foy►lCaiion Y'-..-,r._ Property Line <br /> PAGE PITS i l Depth <br /> t 5 <br /> ._t Nurnbar <br /> UI Oistanw to nearesl: �i Found+tion - <br /> POSat PONDS Q , + s, -- Property line <br /> Well _. ..., <br /> 'i , <br /> ra9y 61nily lnat I have prepared this application And that 1 ej.work will be dono in.s�cMtlLn�* wish San Joaquin county a,tlrnancas, stale terve• ane <br /> r env requlaliOns 01 Ihs Son Joaquln count t`. �,. r +.nco <br />'1e owner or li y ` [ k ` ti '' } _ <br /> tens*tl a4ent's signatvre cartif�es:the 1011owing:"'!cein'lly ihm in*the purlormanCa OI Nlo work for which iters permit is reeves. I shall not <br />��pY any per ton in such manner as 10 become subject to WOrkmsn's eompensatiDn laws Af t:elilO01 1110 CO(k lot w hiring or ywb•cOntraet'ng sigall not <br />'fie, Iha following: "I artily that in the perlormanee of the wgrtstfor whi0h this on la is iaauatl, I shau employ itwt 01 Calilotnla," p P y porton: subject to workman-s compensa• <br /> +paiic�nt t ca r all re uired IntsKc0onSA:Complote drawing o reverse side. <br /> Ti`le: <br /> k -Oaten- <br /> . FOR DEPARTMENT USE ONLY_! , <br /> iication ccapted by • 11 ?��, 7 <br /> Date ` {�roo <br />�+ Gem Inrp4ctivn by Date ` <br /> �_ Final Inspection by Dal* _ <br /> kr'oommsntsr .` <br /> Return a.]..1 copies tot SAN JOAQUIN COUNTY, <br /> PUBLIC IISALT3! SERVICES <br /> " ENVIRONMENTAL IISALTNtDIVISION PERMIT/S811VICSS ` <br /> 446'Ni8AN'JOAQUINO P.O U 2006 STOCKTON� <br /> CA 85201 ' w <br /> FEE AMOVNT DUE AMOUNT REMI17Eo <br /> INFO a; RECEIVED,BY _ _ <br /> atv. Ag <br /> �,.t, � r� OwTEr;.t � ,'Pfgrtll'N0. <br /> 6`7 � �� �_ ' <br />