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APPLICATION k'OR pig"IT <br /> • SAN JOAQUIN COUNTY PUBLIC RWy,TH SERVICBS <br /> ENVIRONMENTAL HEALTH : iSIQN <br /> P 0 BOX 2009, STOCKTON. -A 95201 <br /> (209) 4158-34413'4�v <br /> BAR PRO <br /> (Complete in Triplicate) ry . <br /> L and 1962 and the Rules Gad Re"tlons,or,ban <br /> Applicattoa is hereby a1de,tO Bsut Joaquin County for a permit to cvnatruct and/or install the work herein described. This <br /> spglieatio0 Is sada in aoegtlianee with Ban Joaquin County Ordinance No- 5 9 <br /> JOayuis County Public Health Services. If7T]� sot size/Acreage <br /> 4 Cily� — 15 :ACREST) <br /> Job Addrou 521 <br /> m� t Addtmas <br /> 571 N, C �1�--- Phan. <br /> Owner's No CALCClN dERGY AND ��} r�AAIC}i0 COW <br /> C [�-1� q Doone <br /> Aodrrst )/�J Llcenl!na. _- -- rs <br /> COnhlclar WELL I?EPLACEMENT 71 DESi1SUCTI ERP'l Cf�+t mopi Rif�GSry 0 ell IR <br /> ,Y E WELL/PUMP: NEW WELL ❑ SYSTEM REPAIR ❑ OTHER PR� e �e <br /> PUMP ii15TALLATION ❑ DiSPOSAL FLP _ <br /> DISTANCE 70 NEAREST; SEPTIC TANK SEWFH LINES ��- PITS!$UMPS <br /> FOUNDATION .� AGRICULTURE WELL OTHER WELL --- <br /> I Pr <br /> TYPE OF WELL ?a0l3LEMAREA CONSTRUG7ION SPECIFICATIONS pia a!Well Casing '7 <br /> INTENS. ----»---"-� _"�"'�'� Di+.Cf W+€I Esc+vNion - <br /> fl Induatfi+t ❑open Bottom ❑Mant+ca 1�!c_ -5r.k Specifications-•- 4� <br /> Il TYPO of C+aing <br /> U DomestlolPrivate 11 0 Wavel Pick C7 Tracy t-ot Depth of Grout Seal '�iGl' Type el Oroul�u ° <br /> M PublIc to r��((r':ri 4 �Iher t� I] Delta <br /> 1.0 is K' �Aol>�■• D+Dth d Esstorn Surlica 5401 Inst+lied by <br /> G IrIill;liaR ,`z11{clr"q H.P. State Work <br /> R+P+Ir Wora DCne L7 1 7Y?e 01 f'rtm? ��I f Healing 14iterial G Depth ' f � <br /> We€I f)aalruGllOn ❑ Wa1i Dismstsr _� tiller Katorial +t Dtpth { <br /> Ovptn <br /> TYPE OF 3€DTIC WORK: :NEW INSTALLATION L1 REpAIRlAODITtON C? DESTRUCTION G availab it within 200 le4t�lad II publle wvwr l/ <br /> In+tFflatlon will eery!: Rsaldance COFAM407 lel— O'•hor € <br /> l,,M1, Nu,nbar OI Ihring unite:�.�, Numbst of tedrogmt i4 <br /> Water table depth' � <br /> ChauOler Of wh to a depth of 3 ieos: Capacity.-------- No.Comiserimants <br /> SEPTIC TANK 0 TypelMlg Method of Disposal <br /> PKG.TREATMENT PLT.0 property Line <br /> piaunce.to nearest: Well <br /> Foundation_� W <br /> ------- •r Dial lengthlolso <br /> LEACHING LINE L, No.b Length of linea Property Lina <br /> 0 Distance to nowall: Wall Foundalion <br /> FILTER DID <br /> Sit® Number - <br /> SEEPAGE PITS I I Depth -�. Foundation -Progeny Lint <br /> SUMPS 0 Distance to naroel: Welk <br /> DISPOSAL PONDS 0 <br /> €hereby cvnify that I have prspsred this application and that the wort;will be done in accordance with San Joaquin county Otdinandm state IcWit and Y <br /> raise end regutalfana Of the San Joaquin County <br /> Homs Ownor or <br /> Ilco n such manner t'l,siis torbecolm+s the collo following; <br /> cromr.nation laws California."Contreetor'rihiling of sub•Contraetinglslan1sture 1 <br /> employ any poisonpersons sublecl tO w6tk_ffil�F4 CbrllAdnei <br /> canitWs the!?hawing:"I eenify that in the pirtormance of the work lot vAmch this P+fmit is issued.1 shah employ <br /> lion laws of California, <br /> The appfl:Int must call for NI required inepactionc.Complete drawing on raysrse side• <br /> Title: Oats: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Olt. Area <br /> Applkallon Accepted by D�tt... <br /> Rite Final Inspection b; <br /> ---- - _. <br /> pit or Grout Inspection by.-. -- --- - <br /> Addhlon41 Comrnsnte: _ <br /> { 'p110EWt Return TH SERVICES <br /> all copies tot: E9VIRONMiitiTAJOAQUIN �HBALTHUNT' UDIYl9IOHBLIC LPERMI'r/e$RYIC69 <br /> / 445'11 SO JOAgUIN, P 0 BOX 2009, STUCKTON, CA 95201 �. <br /> RECEIVED BY ITNO• <br /> AMOUNT REMITTED GATE PERM <br /> FEE <br /> AMOUNT DUE CASH <br /> INFO <br /> srl uat Issv.iiesl � <br /> EM 14-N <br />