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APPLICATION YOR PERMIT } <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES k <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)4683430 <br /> P O BOX 2009, STOCKTON, CA 95201 1 <br /> '1 <br /> (Complete is Triplicate) <br /> Application is hereby aade•to San Joaqulo County for a perait to construct sod/or ltutal3 the work herein described, This <br /> application is ands to eagliance with a" Joaquin County ordinance lo. 749 wW JW sad the Rules and Naamisilona of,G3au <br /> Joaquin County N Ule aa+lth flsrviaea. <br /> '✓Joss Address ��✓ s- +r'y �b C�tr� Lot sise/Acr~ <br /> ✓Ownsr's NbrM - � <br /> cell .Cwu- AdasssRsQti „ 3rM <br /> �Contracta Address ��1� �. GJti Llcmit Nd. I; Phone` <br /> TYPE OF WELL/PUMP; NEW WELL C1 WELL REPLACEMENT n DESTRUCTION Cl Out of iea G34 <br /> PUMP INSTALLATION Q SYSTEM REPAIR 0 OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLO_„_.._PROP.UNE'' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> Ll Industrial O Open Bottom Q NAWM” Dia,of wa Eacoval" Dim.of Well C;omok p i{ <br /> ) DomestielPrksts Cl Growl Palpe i L7 Tracy, ' Tyof Cesinp_ Spedlkuloni l <br /> 1'1 P"'w Cl Other ri Dalry": Depth of Grout Sens Type d�+ <br /> k IrriDatlan _Appraa.Dapih I I&Wwm Sullaq Gell Installed by ..p <br /> Rapak Mak Dons U. Typi of Pump Staff Wort Data <br /> WON 00111,04tt O 'WaN.DieltrNr aMl14i Ilatlrlsl i Dsptq r C <br /> r Dw1h pil3ie ffitwriai f) fleyth / s <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 1 I REPAIRNIDDITION I I DESTRUCTIp I NO�sytnt tep wA* +tales awwr is <br /> i VAN esrre: Residrrca Coam'"wNel_ Othv <br /> i Nun"of Nurnbar of bedraonrs. i" S <br /> y. <br /> Ctta 4ow of no to a dap to". with tabM dapltt <br /> SEPTIC TANK O Type/ <br /> PKd. 11lILATIMENT PIT.O 71. # Method of <br /> f <br /> DMmrtae w is <br /> rrenst: F <br /> owtdsdolt .Prppsrty LYte <br /> LEACHING LINE 0 No.i Lara �Olhlfiw [i <br /> " FILTER BED L7 nefroU., WON Foundation <br /> SEEPAGE PITS I I DWh _Site Number 1 ' <br /> SUMPS iE piaanca to rep: iNW,...t Foundation Pwpsny,l yy ° ;� <br /> DIS L PONDS L] . <br /> nes' <br /> -rQnft Wdv that I have preparq Ihb oppka km end that the Wolk mq W dons in sccordan0s with San Joaquin courtly ordwww".Bleb 15%1% 5i <br /> runs and fsprrlstiorta of the Son Joaquin C not,T II ; rt - i <br /> Homo owner a Eicsrlead pM1Ca Wprtature ostufai the fDliawirtp:1,1 Artily thal in the pa1lormancs of 1M work tot which this Antro*is yelled I ow not <br /> employ env pmw M welt manner w to becana rApa m vwtkmati eatsll <br /> a colnption qua of Cahta <br /> nia."Contractors"at sub-conagg*p aipnatwe ``F1 <br /> eettitas the f :'9 MWV tial in Ma fsalofmartce Of the work for which Mia perm*is awed,I MW anploy Meas"4*—t 74 wCamm'a 10 U. <br /> tion Isws of <br /> TM t caN Inysfsctio%-Complete dfawi revamp side. <br /> r/Sinned Date: r +Q <br /> R DEPARTMENT USE ONLY <br /> Appiiccotl n Accoptsd by Dau. Ana <br /> fi ~ <br /> Pit or Orou1 Inspection W Otte Fin*Inspection DY Dari ' <br /> Applicant - Return all copier to: San Joaquin Count! Public Health Sprvlcea , "�" <br /> lioviro,oental Nealth Perralt/Services <br /> 44 <br /> 5 H.Baa Joaautn, h p Hoa 7409, 8tko, DA 98901 . ;�r •. ., -. i " <br /> Fre AMOUNT DIE AMOUNT REMITTED ECNIVED aY DATE100 <br /> ..0 IpAtIDT'NQ, <br /> V <br /> � r. ..$'K,NN'M..w4,y,u.. •a•,�N.t.N,pr.:J,i{[T- —�+ ....I <br />