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' H <br /> F" <br /> APPLICATION <br /> it 1 ; <br /> SAN JOAQUIN COUNTY PUBLIC HEAL II�I#ICES 5— <br /> v \ ENV I RONH ENTAL HEALTH D I V S � <br /> 445 N SAN JOAQUIN, PHONE (20 ) � 20 <br /> P O BOX 2009, STOCKTON, C <br /> PER <br /> N 1A., <br /> (Complete in Triplica1"M# ` <br /> A.pplieat:on is hereby made to San Joaquin County Cor a permit to construed and! J <br /> t% <br /> -h �-Wo '. application to made in compliance with San Joaquin County Ordinance Mo. 549 and 1862 and the }tales and ReNLtione of San _ h <br /> -,Cuin County Puhlic Health Services. <br /> T�.. eat <br /> Lot Size/Acreage r <br /> L <br /> Cay <br /> I Job Addressft <br /> D <br /> Phone a <br /> Address <br /> _. Owmtr's Nart+e s� <br /> cense <br /> Contractor <br /> Addresses 7 G io. Phone SZr k <br /> ? TYPE OF WELL/PUM?: NEW WELL WELL REPLAC MENT h� DESTRUCTION Out of Strriet well <br /> <. PUMP INSTALLATION ^ SVSTEM REPAIR <br /> OTHER G monitoring Vell ❑ t <br /> DISPOSAL FLOPROP.LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . <br /> AGRICULTURE WELL OTHER WELL <br /> — <br /> TYPE PITS/SUMPS yr <br /> ii FOUNDATIC"J <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia.of WON Casing <br /> Cl Irlduatnal ❑Open Bottom 151.blandest Dia of Well Excavation <br /> z <br /> Type of Cawnp__ Spectlicattons <br /> CI Domestic/PTivate Q Gravel Pack ❑ Tracy Type of Grout <br /> .• (-I Delta Dopih of Grout Sear s <br /> 1'1 Pub4c 1:1 Otho S <br /> -t I I krepatgn _Aprwoa. Depth 11 Eastern Surface Seal Installed by <br /> H.P. Stat Work Done Q <br /> Repeu Work pone U TYt»of Pump Staling Hattrial i Depth — `n <br /> Wetl pestruction WeH Dwrieter .?c <br /> Depth / Tiller M►terlsl Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALlAT1ON' I REPAIR/ADDITION 1 I DESTRUCTION 1 I INo septet arm pwmHted 11 pubac tlevrer• ` <br /> availabM wit 200 IMt.I <br /> ,* '4 Ul <br /> IratMletlon wll p": Rasfdonce_ Conwnaf.Hl -- Otlsr <br /> h:lamber of kwV urwts:_- Number of bedrooms <br /> Wath table depth <br /> ' Cherectw of moll to a depth of 7 feet: CapaehY �s <br /> SEPTIC TANK ❑ Type/Mfg RObPOSM A <br /> ►KG.TREATMENT PLT.O CC <br /> y Distance to nearest. Wen <br /> WV <br /> FoundationY(oifr� <br /> � I(( LLSMISI �G t . <br /> mINTY <br /> l LEACHING LINE Cl No.b Ungth of Ines —anon `� f <br /> FILTER SED (3 Distance to nearest: Wttl Fourwat on <br /> 3 <br /> SEEPAGE PITS I I Depth Side Numbed <br /> y.1 SUM►f LI Distance to newest: Wes Foundation PrOMW LYwe <br /> i ' 2 <br /> y DISPOSAL PONOS ❑ <br /> this application end that the work will be done in accordant with San JOagUin county g111r1erlcN,Mile laara.and <br /> 1 hereby CeRitY"%Of 1 have Wopsted <br /> rtales err!tapulatiore of the San Joaoun Count/ <br /> t Hones pegeyr er kwtMd eperlt'I Oi9cwture osnrLes the foWwng:"t COMIty that in the pw/ormance of the work for which thin permM la issued.1 sMM not ; <br /> ertipaoY any Parson in such nwe v me to become subpci to workman's compensation laws of California."Contractors I+rrM19 of sub eontnetirq dpneEtxe <br /> eanNae m <br /> Ma 1 <br /> '1 prigy that in the perforwxe of the work for which this permit is aeued.1 ahwM employ persona subpct to worlinlen's comp~, <br /> tion ltawe W orrVa. <br /> TM• t cal for N r*QL41 tions.Complete a_N on <br /> j Date: — <br /> i deigned <br /> FOR PARTM USE ONt <br /> 024'' '74 Area 02« ��--- <br /> ApoYcetion Accepted by <br /> Final Inspection by AJC Dre <br /> Pft or Grout Inoputiton by _ Date U <br /> Addltbra'C*"~ts: <br /> rAppltcar.t - Return all Copies to: 6�viroupntalCounty <br /> HealthuPale Health t/Strvletavlces <br /> .flti M Sao JOaqutr,, n 1009, Stkn, CA 98701 <br /> a <br /> NFEE AMOUNT DUE Ab1OUNT A(MITTEO CAS RECIIV[0 1r 0 I /►�111�MIT'N0. <br /> vVV <br /> .. Iw ILN MN.treat t <br /> • rr:,`})tl t .,err., _ f' <br /> INFO <br /> �`����� T,�. "�,�/•An... - <br /> �k Nig V 7 ar <br /> " � ' wlr� �w �C,�T•1''Riy ty1��t� ���`7('�,^�/X 4 Y A1 <br /> �. .,15 , t f � � _ �-}d'4,tr 1�in�'eC'u`�,t l;r.• f�s <br /> ti •. aa <br />