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r A a <br /> e s <br /> A <br /> t <br /> AFPT.ICATION FOR prsaMIT <br /> SAN JO,.jQUIN COUNTY� LIC DIVISION <br /> VICES <br /> ENX 2009, STOCK nN, CA 85201 <br /> p 0 BOX 20Q91 <br /> (209) 468-3447 <br /> (Complete in Triplicate) ,his <br /> Permit to conetrrst and/or install the voes herein tio�of Dart <br /> s to San Joeyuin County for a Pe Ordinance Na• 5�L9 and 1,62 sad the 1tu1 <br /> guls <br /> Application to hi.reby pad uin Count? <br /> application ie Call <br /> c0epliartce vita Ban 3oaq r <br /> .� Joaquin County public HoLith Services.4 City �� Lot BiselAcreaBe <br /> a <br /> Job Address Phone ----- <br /> s Addresst <br /> owrw,s Nems �jam-^--i ���-�7��eti{ y�� .s� Pnone <br /> License No. Out of Service well CI <br /> Address `� DESTRUCTION G well <br /> Contractor WELL REPLACEMENT n OTHER 0 MtvnlWrir:1E <br /> NEW WELL f7 SYSTEM REPAIR U <br /> TYPE OF WELLlFUhSP: PUMP INSTALLATIIO PROP.LINE , <br /> o! DISPOSAL FLD._.-� PITglSUMPS .� } <br /> SEWER LINES ---- OTHER WELL�1 <br /> DISTANCE To NEAREST: SEPTIC TANK AGRICULTURE wELL ��--- X11 r <br /> FOUNDATION NSTRUGTION SPECIFICATIONS .t+ <br /> _ T�rPE OF%Ell PROBL,EtAREA C��. Dia.of Wetl Casing <br /> INTENS �r 0 Manteca D,a.Of Well ExC+Val an G Specifications <br /> Ll Industria, ❑Opan Bottom <br /> Type of Caainp Type of Grout <br /> Et Gtarol Pack C]?racy <br /> .— U DOmestielPriv+te ❑Delta Depth of Grout Seal �^- � <br /> L7 Publk (1 Other Scenics Ser!Installed by <br /> Y APIxOx.DePth ❑ Easurn State Work Done d� <br /> G Irrigation Type of Pump FS. 1 <br /> Repair Work Done 0 gealing Material &Depth <br /> Well Oestrudlcn Cl Well Oian � rill-Material i Depth <br /> ,mitied it p::bGC eawor is <br /> Depth available w,thm 200 feel.) +1 <br /> TYPE Of SEPTIC WORK: NEW[NSTALt1t710N Ll REPAIRrADOITION L1 DESTRUCTION Ct Ileo aaPt,e xy>!tem T <br /> vysd some: Rosidsnee Commefeiol Other�— <br /> InstaGation �Weter tabte depth <br /> Number Of"++nits: Number of bedrooms Compsrtmsnte <br /> �-- <br /> Charactn of 601 to a depth of 3 fest: capacity----- <br /> No,d Type/Mfg ;4Sethod a1 Disposal <br /> SEPTlC TANK <br /> Property Line <br /> PKG,TREATMENT PLT.Ll to merest: Welt <br /> Foundasion�— r� <br /> Distaner <br /> Total tengihlsi:e <br /> CHING LINE Ll No. Foundation�-�!S Length Of lines Property Line —� <br /> LEA <br /> FILTER BED L1 Distance to Mucron: won <br /> Number <br /> I I Depth ----Sire Property Line <br /> SEEPAGE PITS Well �-�--^ <br /> Foundation�� <br /> -^ SUMPS Lt Distance 10 nnasrest: <br /> DISPOSAL PONDS fa r this aPpheation and that the:vork will be door in scco•dance with San Joequin county mdrnences,state favvs.and <br /> I hereby certify that I <br /> have Pr+P+ I testily that in tar performance of the work for which thio psrmlt o tnurd,1 shale not <br /> rules and trgulationa of the Son Joaquin oun rte the lallowFnq:' nss• <br /> Homs ovrner or licensed agent's siq w persons sublet[to workman's cDr►We <br /> n n of me wort for which this permit is issued.I shall emplo, <br /> a rdaR in such rrynMr as to dome subject ct IO wOfkmen a COmPensilian laws of Gslilorma•' GOnlnclo!i 111r1nq Cf fU�CanlnCtinq Hgnelure <br /> employ Y rforma <br /> certifies the following;"I certify that in rtes W <br /> tion Laws of Cehfomis." Datr. <br /> at call all rod plspaet' e.Complete drewle: voce side. <br /> Thea Title: <br /> 144v— <br /> Sigr»d <br /> FORD M ONLY - G Arra <br /> Data_-- <br /> Applicatlon Accepted by pHs Final Inspection by <br /> Pit Or Grout Inapocilon by <br /> _--�—� <br /> Addrtlonel Camt ants: <br /> ETiYIRONw6IiTAL 1lEALTIi7U9" BIOOKTON, CA g52G1 <br /> A,�pliesnt 1"u" LU eopise tat BAN JOADUIN COITNTY PUBLIC H1IALTN,'BI TISETt8 <br /> 446 N SAN JOAQU111r p DBOX <br /> DATE fENMIT'ND, <br /> RECEIVED BY <br /> FEE AMOUNT DUE AMOUNT REMiVED CASH a q/4 <br /> INFO / 1 <br /> iH 13-74 taN. <br /> [H:1•al <br />