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1 <br /> 1 <br /> APPLICATION. FOR PSR1lIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EYVIRONMTAL HEALTH DIVISION ' T <br /> P O BOX 2009, STOCKTON r CA 95201 <br /> (209) 468-3447 PL! ,y�VA ' 1Sgz <br /> PSRLIT SRPIRSg YEAR I►R DATE I8Q SD`ryvrR^.n`I H .ai lfY C0<t';-v <br /> (Complete in Triplicate) tirT(rycJ it,IS <br /> ApPlltatlw Is hereby rde,to 8ao Jtxquih former tar a permit to constructwine and/orA� l !taiII . 300vork LsO�O described. 'Yhis <br /> Joaquin County Publlongealth130 Services. Ban Jo.gula County Ordina11ee No. Sk9 and 1862 aid the Rules and Regulations of Ban <br /> Job Address 237'_3 4ARi ftSEROAnch S'hxl<+on/ .Be S.4CRES <br /> Y Lot 1112*/Acre <br /> Owner's Name ``kisecRoug MA it Address 2373 AIAP/POCA )ZO Phots 4- 7G39 <br /> TYPE <br /> WEL ERBEIRsE STEuLdar �+ dras2X2312roErtRD AIr17ESTI7 License No. na -L 7G <br /> TYPE F WEIL/PUMP: TI Phone <br /> NEW WELL O WELL REPLACEMENT O DESTRUCTION O Out of 8ervia Vell <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER IT AJrJzQr1n Veli O <br /> DISTANCE TO NEAREST: SEPTIC TANK 7,,_. SEWER LINES :&n _y DISPOSAL FLO.{rn_ PROP. LINE Lvalo s. <br /> 'T <br /> FOUNDATION X00• AGRICULTURE WELL OTHER WELL.1sOM' PITS/SUMPS dmhe- <br /> INTENOEO USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS <br /> O IndustrialO Open Bottom O Manteca Dia, 01 WW Exavaan <br /> Dia. of Wet Casing #/A Gvel Pick <br /> O Tiley Type of Cssirt9�A<r� Specifications--d�A US <br /> O Public Kolhar O OMta - Depth of Grout Seal SURfALE <br /> C1 Vrgstion Type of Grovt-C.4r <br /> 4 Approx. Depth ❑ Euern Scalia Bull InsuOvd by r"MACJ*P <br /> Repair Work Done U Type of Pump H.P. <br /> Wet Destruction O Wen Diameter 8sa11og KataDepthl E Depth <br /> Sus Work Done_ <br /> Depth Tiller Material E Depth <br /> TYPE OF SEPTIC WORK: NEW•INSTALLATION 17 REPAIR/ADDITION O OESTRUCTION 0 IMO septic system permitted if public sewer la <br /> butst+tbn win Sarva: Residence_ available within 200 feel.) <br /> CommatdY_ Otner <br /> Number of flying units: Number of bedrooms <br /> CltAraaa Of wt to a depth of 3 ben Q/1 <br /> SEPTIC TANK. O TYDe/Mfg Wsta table depth <br /> PKG. TREATMENT PLT.O Capacity No. Compartments <br /> Method of Disposal <br /> Distance to nearest: WW m <br /> Foundation PropertY Line r(�` <br /> LEACHING LINE - � <br /> O NO. 8 Length of fines <br /> FILTER BEO O Distance to nearest: WellToast length/size <br /> fa11ndi110n ProDertY line <br /> SEEPAGE PITS I1 Depth <br /> S'ae <br /> SUMPSmber <br /> ClL'I Distance to nearest: Wen Foundation <br /> DISPOSAL PONDS -O Property Line <br /> 1 hereby artily that I have pr11Pared this applttatlon end mat the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rulss And//191141110115 of the San Joaquin County <br /> Home Owner Of licensed Agent's signature artines tM following. <br /> emPloY any Paton in such manner As to become sub. workman's"Id(Y.lhal In the penormanCs of the work lot which this Permit is issued, 1 "If not <br /> utUlas the lotawtag;'y eanity that in tne performsna of the work for which Parmh 4 4 f C I gnat employ <br /> hiring or sub-contracting signature <br /> tion laws of Cafilorrtla.^ mploy Persons subject to workman',compeass• <br /> The appllan at I requir d ttspgctione. Compete drawing on swap tide. <br /> Signed Title:J'or 4( tun Dee: Ll/M /G,/f9a <br /> -FOR DEPARTMENT USE ONLY / <br /> Apptcalon Accepted by _ �'r"' �— Date Z 36 <br /> Area <br /> Pit or Grout U!spectbn by Dat11�—� <br /> rDare <br /> rneFinal Inspection by a s <br /> Additional ComnW S'�3 <br /> Appllceat - Return ail --..._s tot p <br /> "•" BAN JOMQUIaI Q01011'Y <br /> VIRONRFNTAL PUBLIC NZALT1 SgRVICXS <br /> 9118 N SAR JO./p {� <br /> PJIS , .DIVISION PMWIT/SVIC88 <br /> FEE 2{ <br /> UIXT1RRP O BOX 2009, STOCXTON, CA -93201 <br /> WFO <br /> EfCA,04I(:9::Rl!C1lVED y OATF <br /> ►ERM17'NO. <br /> W q•N MeV.ue ter 19+. <br />