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A,6+ <br /> APPLICATION FOR PERIAIT <br /> Stiff JOAQUIN COUNTY PUBLIC HELL.TII .SERVICES <br /> ENVIXONil U-rAL UEAI.TE DIVISION <br /> 16D1 E. HAZELTON AVE. , PHONE (209)46$'-3420 <br /> ,.r P O BOX 2009, S'TOCKTON, CA 95261 <br /> (Coaplate in Triplicate) <br /> ayiSScaLltaf Ss heretgr Gads,m Sao docqul¢ County for a De rmil to eDnatrueG andf or Ina tail -the vork herein deetrdbpd• 'YRS' <br /> appllcat7ea S■ Rada Ln coolpliaRca xL:b sari aoequf: Cowily Ordinance Ho. 5u9 and 1862 a<�d t!»Stlea e16 Pe3tt1►.tlone Ben i <br /> Josquln Cmgmty Puhllc Health 8ervlcoe• ; <br /> City A LoL SiselAcraagc <br /> Joh Address [] <br /> P o i;n� �O� et Phony ~ <br /> Owners HAFT Adtlfesa VV <br /> f <br /> rp�a-til e.7 «n>a eta. <br /> Cantrattt�jla0d��t gaddrets <br /> TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLA!;EMENT i1 DESTRiJCTiDN ❑0ut at itairsce 2l s <br /> f4gtt1Loslpg it ll <br /> — PUMP INSTALLATION ❑ SYSTEM F.FPAIR Cl OTHER O ; <br /> St"sYyEiA LIMES OISPOSp.:FLD. PROP,Lfhti �......_ ,' <br /> DISTANCE TO NEAREST: SEPTIC TANK P175/$UMP3 <br /> FOUNDATION AGRXULTURS WELL _ OTHER 1mJfLL t <br /> WTENOED USE TYPE OF WELL FRO6LEM AFtt:A CONSTRUCTION SF`-CIFICATIONS j <br /> E�Open Bottom ❑MantaCp Dia. of WBII EH uyrtioDia.of Woll Casing <br /> n.�.�--• <br /> t1 lndustriat Speelficallons f <br /> r3 0arrims0OPlIvi te, ❑Graysl Pack CS Tracy TVV@ of Casing-_ --�--- <br /> r.Doi Depth of Grnut Seal Type of Grout <br /> I'%Public 1.1 Other d <br /> I i laudation Aprwor.Depth I I Emnern Surface Seal Insulted Ly..T�� 0 fp <br /> State Woru Cone f..,.-:_.--•------ <br /> Repair Work Done V Type of Pump H.P. <br /> ling IhWrlal 4 DaPtk <br />` Wed OsstrucWn D Well DiemEteaetet Piller Material a Dsyth --�-�--- <br /> Depth <br /> TYPE OF SEPTIC WORtt: NEW l?1SilELLATION FEPAIWA001T1:7N!I OESTRUCTIFN L i ayadaUb+within 200 iaelt-l�d pubs soup is _ <br /> i <br /> InsillUMn W"serve: Rn;danea�ConttndItiel her. f ; <br /> Nurnbef of who unite:• ' - Number ma rt <br /> Water table depth <br /> Cheractar at soil a a depth of 3 fast: No.Cornpa+ttnenis , <br /> SEPTIC TANK sx TypeWfg Capacity <br /> PKO.TREATMENT PLT,L) ��l� l Method of C'Wosef <br /> pistanee to rtaaresl: Well i J:^�_ Fouatdatiwl�- ftpp•ty Lina ` <br /> 45 <br /> Tosal — <br /> ian6thlt}xa �i - <br /> LEACANG LINE tVo.B Length cl eines r r � <br /> FILTER 860 M Distancti to 001`11111- Well _�Q4� <br /> Foundation�±.� PrapenY Lina-.r� <br /> Uepth Siaa lumber <br /> SEEPAGE PETS ! <br /> {• 1 -'�� PraParlY Lina <br /> ' SUMPS LI Oatwrce to rtsersst: Well J,�.r?2,Foundarron r <br /> .f <br /> DISPGSAL PONDS ❑ a <br /> I hereby,Ntsify tnat I hfvs prsperod glia iPplicpCq^and shat me�wat.%will oe done in act0rdance with San Joaquin minty ordlraneas,stats'wa,and - <br /> rules SF4 rapulatrans d the San JoWuin Countyj <br /> Miatrse b+mar 01 Iiesnsed aGartt'i alpneturs eN 049 She folLdwmg: ,I certify that in the performance of the work lot vdtich this permit ip bauad,I all rsot <br /> employ any person kt wch menrrer aF to become sxtapect to workman's compensation laws of CsYfaraa."Comiractor's lking ar sub•con;r Ce ng i"ture <br /> eai'tlfiea ties farofallittviWk w b certify that in this performance of the work for VOICh Lhiaperrr"is iaaued.I t hall employ parauns subjaet ro wort.mcri a nae' t <br /> efon larva of CaHlotNa." 'l <br /> The sppliwns eL wN IIx In n4Uus4 tnspeelione,Coneprare dra+rinj on nwse r ,sirde, / <br /> l3lgmd Title: V.p —� �-- Dote: <br /> FO OEPARTMENT USE ONLY9 too <br /> 'f <br /> Oats_vr. ' <br /> 'Applicadt ro Accept . <br /> ' P!1 Qra4t inspection by �d_- <br /> Det• Find InepectioBF y_��� p � <br /> Addittanei CommSms: <br /> ApplEcaot ^ Retort. Pili oopiaa tc: rmu,Joaqul4 CoLL:Y Public Health <br /> services, 88riromrent.Al Bealtb FeroitJ:'arvicea <br /> 16.n1 S. Huteltoc Ave., P 0 Bcx i?N9, Stoclttoe, CA 55201 <br /> if <br /> FEE AMOUNT DUE AMaUE AIfIMA TEO C✓~H RECEIVED BY SAT( PEP.MIT'ND. <br /> iNFO - •--.��.• <br /> .EX r7ta rtlN..r a � �/.C�r lzy fr•.1V'!� ���•��d <br /> sN•aas _ <br /> i <br /> j •d 9EL5-59,5-6[32 •vuI Suta6 I .g5TJued •d •Q Wd91 :6 LOO2 Ll Uee <br />