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yw <br /> >} i <br /> . . <br /> APPLICATION <br /> �5 <br /> NUiN COUNTY PUBLIC 11EALTU SERVICES <br /> a <br /> AI <br /> VIHONKrNTAL ItHALTH DIVISION <br /> ` t �D SAH JOAQUIN, PHONE (208)468--3420 �►�S <br /> P BOX 2009, STOCKTON, CA 85201 <br /> 2 n A <br /> NY (Complete in Triplicate) +. <br /> Cation a hereby rade to Ban Joaquin County for a peralt LO construct and/or SnlN.tl the vork herein described. This <br /> o �? <br /> application le de la cot�llance with San Joaquin County Ordlnanvo No, $49 and 1662 and the Rules sad Regulations of San _S <br /> Joaquin County Public Healt <br /> h <br /> Services. & 10 Ac_ <br /> ..k;Job Address: f * ,�' !�I_.e. C•rvC Lot St to/Acreage l } <br /> Fti. Owner'sm <br /> Noe _ -OF-20 Address � 7"1 1 .�u�C'__L `f Phone gz 7`f6o3 <br /> s e Contractor t Addiest LiCense No, Phone <br /> ` TYPE OF WELL/PUMP: NEW WELL 13 WELL REPLACEMENT fl DESTRUCTION ❑Out of Service well 0 <br /> � - Sonitori Well <br /> PUMP INSTALLATION 0 SYSTEM AEPAtR ❑ OTHER 0 � ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWiIR LINES _ DISPOSAL FLO. PROP.LINE <br /> xRS FOUW.ATIQN AO_R.CULTUAi WELL OTHER WELL PITS/SUMPS <br /> w�a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> #Tr vr. <br /> _ 7 i; r❑Industrlel�. ❑Open Bottum ❑Maniacs Drs, of Well EMcwa'an. Dia.of Well Casing . <br /> 0 Domestic/Private 0 G(ave1 Pack ❑Tracy Type of Casing_ r� Specifications <br /> V I Public i ['I Other. Il Nita Deplh of Grout Seal Type of Grout <br /> �, ��+i!Irnigshon3; APproa.Depth I i Eastern Surface Sour Installed by <br /> al <br /> Repair Work Done Ll Two of Pvrnp H.P. Slate Work Done_. <br /> t ». Well Destruction ❑F We4 Oiamater Bealin4 Material i Crpth <br /> Tiller Material i Depth <br /> Depth p ; <br /> k; xiATYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I: OLSTRUCTION i I INo sopic system perrrutred it public sewer a <br /> sredable within 200 faet.l <br /> '' Ili{taiitiatt will ar" 'Residence ComrrretcW Olher�' v"" 76=r <br /> i <br /> Nwelp�r of&*v unim Number of badracim <br /> ChIsractu of eo4 to a depth of 3 lea: Wales taWe depth <br /> . SEPTIC•TANK _; O'Type/Mfg - - — Catyelty_ No.Canpartmants <br /> P.W TREATMENT PLT.CI Method of Disposal <br /> Distance to nosiest: Well Foundation Property Lina �• <br /> ^ LEACNING LINE Q;-leo.i Length of lines Tout length/tiro <br /> FfLTER IlfA d Distance to nearest: We* Favocab n Property Line !? i <br /> 8EEPAGE PITS !I..OWh Size ' Numbet r <br /> sU1AP3 Lt., Distance to nearest: W1* Foundation Property Lina t <br /> Df1iP0$AL PONOS w ❑ K�. <br /> I he!MIy.cMity that I have,prepared this application and that the work will W done in sccardance with Sen Joaquin county ordinances state laws,and <br /> f:' rattle ettd rpulations of the San Joaquin County <br /> Nar1M owner&MCansed agW'i signature ovitifies the following:_"I certify that M the pfifermanea of Cho wort for which thio permit is issued I$half not- <br /> a iplotr owmaaion in such onamw as to become subloct to workman's Compenaition Iowa of Call this."Contractor's hiring at suWcontmcting signature <br /> =WIN oli falowirq 1 cW*that in the podormar"o1 the work for which this permit is Iowed,I shall employ persona subject to k n':compensa• <br /> F tin litre � t/ <br /> Thi td —Pectlans.Complete drawing on evsrso side. /1 � T�C���.2 n'� '�� <br /> sa; # rut �. J;�r�'_ Dat.: 91-.2--134 <br /> FOR DIPARTsit4NT U24 ONLY <br /> Appix�ti ,h.ti' f]sis ` Ane <br /> ia.tfon Acopted by <br /> P4 or tEfeul InapetHfon <br /> Date Final Inspection by Dae <br /> ; ' f r <br /> AddNbnM Comments / <br /> Appl scent,- Return alllizoplea to:"Rao Joaquln County Public Realth rlervleea <br /> _h.U�(,j,r••. '. Oyj Z _3•(�'y,�S/Kibrlrootwntsl stealth Perrlt/tferriCealJ - <br /> 445 N Ban Joaqula, P O Box 7000. like. CA 08701. �' r'' S �� �!,i✓ . <br />[[' tNFG AMOUNT 0V[ AMOUNT REMITTED CASH AlleflVtD IV- PATE - <br /> .`satstllavvaei tJ L/� <br /> $ ai Y - <br />�'.. VY(Hi""wrMw+*�W+MJF$'F�y�.lit'Y:�AMNr+Y�wwrr-�, it <br /> +dam <br /> t . <br />