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APPLI C ATIUN F01( PhIt1f 1'I'
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL IU ALTH DIVISION
<br /> P O BOX 2009, STOCKTON, CA 95201
<br /> (209) 468-3447
<br /> PRRMIT L HIRES 1 YRAAP FROM DATE ISSUED
<br /> (Complete in Triplicate)
<br /> Application to heresy lade to San Joaquin County for a permit to construct and/or install the wort herein descr'Ded. This
<br /> ajpllcation Is made In compliance with San Joaquin County Crdinance No. 549 and 1862 and the Rules and PeflulAtlOna of San
<br /> Joaquin County Public Health Services. J
<br /> ,L /O L���,r L i`) r (,� _ C tr_�4i.+.__ Lot tllte/AcretrSe 6 -4 ��r�r
<br /> JOD Address ,/ /� I
<br /> a
<br /> Owner's Nome �.�'r `_S J7V C -_ Andress v/�" , _C_/�"� 1 Lc _ Phone c
<br /> Contracla C �•' `r - -Address No 5-5—In Ov Phone
<br /> TYPE OF WELL/PUMP NEW WE1l C WELL REPLACEti'ENT 7 DESTRUCTION C1 Out of Service Well ['
<br /> P�'
<br /> .- ••. .-ALLATION C SrSTEM REPAIR " OTHER [ IOonttorirl6 tell
<br /> DISTANCE TO NEAREST: SEYT,i, TANK _— SEWER LINES :iSPOSAI FLD PROP. UNE
<br /> FOUNDATION AGRICULTURE WEII OTHER WEII PITSISUMPS _
<br /> - i
<br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> Induanol U Own Bottom 0 Monleco Oro of WON E■covalton_ Du of W/a Camp
<br /> Domeanc%P,wate Cl Gravel Peck 01 Tracy Type of Co" Specthcatrorta -
<br /> C P„biK CII., L Delta Depth of 1310.1 S” Taps of Grow
<br /> a hn0.non _--
<br /> ADI-'=- Cspth 0 Eastern SuA�ce SNl•utalled br
<br /> Roos-, Work Dore _' Type of Pump --___ H n _ -_ _----- - --- -_-. State Wo,k Done-_ --
<br /> WON Destruction C Wall D.ametet
<br /> ee:lt4 Naterla. s Cepth
<br /> Depth _ Tiller Material 6 Depth
<br /> TYPE OF SEPTIC WORK NEW INSTALLATION 0 RcPA1FI.ADDITION C DESTRUCTION C INo eeplic system pernwited if pPOl,c sewer a
<br /> ova-lable tivllhm 200 1641.1
<br /> Installation vvdl so" Residence_ Commercial Other '
<br /> Number of Nwnp units -_ NumCs,of bedroor•is_ 55
<br /> Charwor of and to a depth of 2 feet' /'`9n 42t E- E`�-� _.--—Water taper depth
<br /> SEPTIC TANK 0 Tvpe/Mtg ��'t*�s Soy-fwua_l3 No.Compartmann
<br /> PKG. TREATMENT PLT.C1 I / Method of Disposer
<br /> Distance to nsa"t WON#1u1a_ Foundal,w, Property line +
<br /> 7 /Q
<br /> LEACHING LINE LQ No 6 length of lines =_.l�0 7—
<br /> Tour,engthrpm4 i v
<br /> FILTER GtO CI Distance to nearest. WON,,jp_QPuundatan 1 -_+ Ptopenr LIn4.[��
<br /> SEEPAGE PITS 11 Depth S,a'O Number
<br /> SUMPS Ll Distance to nwretr WeN Foundal on Property line_
<br /> DISPOSAL PONDS 0
<br /> I nsrIDY CerOfy that 1 have prspofed in,$audKal,on and P,.1 the work .+�.�tie ddne in accotoance wtlh San Joeoum county ordinances.stall laws. and
<br /> rules and regulations Of Ins San JOegwm County
<br /> fpttp.v^p I ren�l� that m the pO�n••nance no Ins wOrl fOr which this 041m,1 H oawIn 1 shall n
<br /> Moms owner or bcansed agent a voretu,/c0n.f4l the I
<br /> m
<br /> eptor any poison in such mannrw as to"tome suhfect to A:s%A on a compon"l,on 4wa Of Ca fO,nia .COntftclOi a hiring Or aVD Co 'fact apna u a
<br /> Nn�f,ee the rONOwmg "I tMdy that M IM peAoimM�e tat Pre hO,►for..•t ti this pe,.^,t V ill•.eO t shah employ persons subject 10 wOrkman'a COm04naa
<br /> tion$ewe of C01110rnIA"
<br /> The or4)kanf nwst call for an regjuad,nspeiri nv.s Complete d,e+.,ny m rev/O,w side
<br /> Signed `.✓�� ! <<_�. �__ _ TIN �.!,fr�3�''�--� Date-
<br /> %A%
<br /> �Z-y tf
<br /> --•--•�-+� }} � ��/OR OEPAIITMENT USE ONLY (��q 5
<br /> Apolicst,on Accepted by [-'�'� 't'V -..__�� MAaM 4'O► ----- Dote�,,,�„�.��--1•� Arlt��
<br /> Fit or Grout Ineoection by Inewci,w b._�.
<br /> � c Mate
<br /> Add,uonst CommOnos -
<br /> Applicant - Peture all copies t^. 3A.N JUAQUIN COUNTY PUBLIC HRALT11 1KNVIf B9
<br /> VXV1k,'NMANTAL ItEALTH DIVISION PKANIT/H6HVICES
<br /> aa'� N MAN JUAQUIN• P O I10X 2000, UTUrklUN, CA 05201
<br /> r�l�T MUUti• Dl, i •M,♦�h' HIM"l0 i ? nf�F�V{D!r DATE FIRM" NO
<br /> ti1D J/ I _ I ' ^� • C
<br /> -of,
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