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+ 't r""1 APPLICATION FOR PE'0""_NT
<br /> F
<br /> w Y SAN JOAQUIN COUNTY PUBLIC HEALTH SBRVICI;S
<br /> ENVIRONWNTAL fi$ALTII DIVISIO!`
<br /> h..., 1601 E. HAZRL70H AVE. , PHONE (209)968-3420
<br /> 4 P O BOX 2009, STOCKTON, CA 95201
<br /> �' � Lf.�R_FROd flAT12 TRcrirr. �_ .
<br /> (Complete In Triplicate)
<br /> �'. Application is here h..
<br /> eppllcc
<br /> Joaquin
<br /> County
<br /> is Psden oWliancel withuin SanCJoaquin County for a ty orddn nceconst
<br /> Roru5k9and/or
<br /> l8ti? and the Rules ande vork epegulatio described.of Sana
<br /> ' Joaquin Coutlty Public Health Servfces•
<br /> Job Address � ` '(� ,¢��
<br /> �4+--��'-���.�,._ CirY—.Fl Lot Size/Acreage
<br /> K ktr '
<br /> Owner's Name Address Js• �Q .SY."2 , ';'';" : r1,
<br /> _^Phone " r Y
<br /> r
<br /> Contractor ' ' G L t Q
<br /> Ad7
<br /> R+l ° dress, [ -11_ Z_ -MTL�"j�T Llcerrse No;
<br /> _f TYPE OF SYELL/PUMP: ;.NEW WELL L7 WELL AEPLACEMEN7 ,] Phan'
<br /> " DESTRUCTION C]Out at service vel; (] r
<br /> �r PUMP INSTALLATION 0 SYSTEM REPAIROTHcq [; Iaonitorint you
<br /> a it mow'.- -4-NICE TO NEAREST:_SEPTIC TANK
<br /> SEWER LINES
<br /> DISPOSAL FLD.' 'r'ROP.LINE
<br /> FOUNe1ATlON AGRICULTURE
<br /> !y WELL OTHER WELL 'SVMPSPiTS
<br /> c tNTENq_E^UBF. - TYPE OF WELL PROBLEM ARFA
<br /> CONSTRUCTION SPECIFICATIONS
<br /> ,.fs; i ❑Indusbwt- O Open Sonam ❑Manteca Dia.of Well Escaverkyn
<br /> B a Dla of Well Cai'iQ""v Fw'yi + f
<br /> !.r Dome 'IcR ware x r Gravel Pack'' •f]Tracy T Ir
<br /> rTr 5 1 I lic "
<br /> Type or Casing____
<br /> Pub
<br /> I:1 Other I']Delta
<br /> _ Depth of Gro+rt Seat ' ��,• Typr of Grout - r_, '„_,�•<`'1,�
<br /> ' , p I i drigrrion - A prat..Depth I I Eastern "Surface Saul installed by - °•` "...:. "r '..,.* a �.+ anFi.
<br /> o' Aeoar.Work Done, 13 Typo of Pufni, H.P. v
<br /> aX �r gl-£.,F'"eq Oestructk"I Q Well D`,'`rerara R Sealing FLLterial 4 Depth Stara Work Oona '..,r *S, ^�5, 1 O7
<br /> _ I ' Depth _ Tiller Flaterial R Depth Y yr 1 �I
<br /> tp ttefrr I. -yTYPE Ot• pYt+:
<br /> WORK.♦NEW INSI ,cON I II REPAIRlADDITIO D < fit'='1..�V
<br /> :, -tom y J
<br /> .,,a' MiE5TRUrrluN I,f 1No septic sYuem permittmf d
<br /> pltblst
<br /> ova table within 2W feet.)
<br /> rve { „
<br /> S, ,,.. Inatagrtion wig se ,*Residence_Zf C'ommerciV Other - r�� e� •,I "lr rI
<br /> of livirg unIts:_ Number of bedrooms , -
<br /> �.4 ,5?r erecter of roll to a Goth a!2 feet:' a /ti� iJ r i n 4
<br /> EP F TANK Q.LiTypq/Mfg depth
<br /> y r _Water table
<br /> r }kf�•.Sro * h�..
<br /> REATM:v.'PLT.Cl,s ' C+PacFty No.'Compartments
<br /> + �.
<br /> 4r Y(y�5 Rr Method of O' al, k
<br /> Ditrtance to newest well
<br /> +ti dtI r t'LY.s °, d s arm, T Foundation Property Line ` r' ,4
<br /> �.. .LEACHING LINE t;(, no..&Length of Imes
<br /> loyal length/size 0" 777 "?4.erxlvirv_4
<br /> FILTER 8ED ! 'D Distance to nearest Well �' 7" Property Lln.� Fr '
<br /> ���t;Zri;,�F:�d:^l.s s 'L.C.
<br /> ixSEEPAOE.PIT6 t ]DePlh -- �_S,ze
<br /> , }
<br /> 4 _ N 7rrbel •, r z a�i Ft'ur y `"
<br /> " '�l- Dlalarlea to newest Wig
<br /> ' "i %J�2i
<br /> DISPOSAL PONDS • C7 k"1 Farndafroni. Prnprty Lir» aj o- l> +c 3
<br /> l, y - : :. _ _ - .• yr, U�,r:r Y4 1! 7E.+ +i "Ph, ✓ti ;kCgo�, iC' .
<br /> ¢Fr taraby nrtify that I have preparedthis applrcatlon end tiler Me work wig be donein accordance with San Joaquin county ordlrlances stateulei ant!nr or ions of the Sen signature ceuaty y �,
<br /> r•c 1r HtMx'owvner tx litenaed agent's signature ceRiCles the latlowin 1'' _ �r
<br /> Dlpy any PMson in wch manner as to become sub' ct to work men's„compensat o 4ws of Cacfa�rw ectTN work nr c hiring orpsub ci ntraeemdg signaN not
<br /> tu
<br /> X”t Vii' en'fi"the fagowing: I certify that in the'prrformanre of the work for wh!ch this perm t Is INuad,�shall!n'
<br /> ._ !ion'tawr of l:affforala. -ObV parsons subject to wrarkrnan's t
<br /> --'.'-� .`�. .�i. �.� � d�}, + ' CalrFPenaat
<br /> ? The applicant nwst CAR for sll uWW In plate " x _, k, lP PRI:% I I
<br /> req spy<[iona. Com eta draenng on reve.se side y h I, )yW
<br /> v r /� }' 'fir „ V a k '3 x t
<br /> 4 t / r �,.� C k E 4
<br /> •. � r7ate
<br /> J 'rTr EOEPARTAAEN7 USE ONLY
<br /> R Da} + it i a{zlrj;
<br /> r�tAppiieation Aeceotrds
<br /> t�i Area
<br /> -2- Pk W Grout Inspection_by
<br /> r I Data Final inspection by late I j/ i
<br /> .w *�AddkbrsMeCommenla: ` i $ :� `
<br /> e
<br /> 4ygih rAppllcstnt`7Return all copies to: Sari Jorquia County Public Health 1 -%F
<br /> w
<br /> � ' Servicer. ltvironmentsl. Health Permt/Servicer �t !� r� i I°=
<br /> .t r 1601 E: Paselton Ave.. P 0 Bax 2009,.8t6cktoo. C19M.1", ?'
<br /> � t% fit
<br /> AMOUNDUE /y tNT REMITTEp C,1 0 CA
<br /> S+ , Y ... npATE, Mr 1T 0,f
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<br /> �FM 74 rr J Q
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