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SAN JOAQU IN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOE 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application in hereby Reade b San Joaquin County for a pereat to construct and/or install the work herein described. This <br /> application is aside in compliance with tan Joaquin Courcy Ordinance No. 519 and 1562 and the Rule• and Regulations of San <br /> Joaquin <br /> r' County <br /> Public Health Nev <br /> JobAddress I/My 601 ST _ C''WAC_l l.ot Site/Acreage <br /> OwmraNam. L&A CC0111S Addesss —AW1 Pnm L /� <br /> E <br /> Contractor 161 - Add,A(1Ad� )( Jf30d �S / <br /> L.Cnnte NO. Phone` <br /> j TYPE OF WELIJPVMP. NEW WCLL,U._ WELL REPLA_,_(MENT [1 DESTRUCTION 1-1Out of Ice Nell <br /> LI <br /> PUMP INSTALLATION CSAN JOAQIHNSSBLHuA>1EpPMIC HEALTH SEOM N°nLtorin Yell E] <br /> DISTANCE TO NEAREST: SEPTIC TANKPROP. LINE �! <br /> I FOUNDATION AGAR 'TURF WsE[L*r1M 1P T11ENAVp.I AS' TS,3VMP$ <br /> INTENDED USE TYPE WELL PROS LEM ARE CG}IpI P I l A OI AS~ Ai <br /> Il IMuatral ❑Open Sottorn -" 5-M ame ��y�T��QP��r • °�'l Ola.-ols(NW C•sinp.. y <br /> fl Domenic/plrosto ❑Gravrl Pack ❑Tracy rilEg'b e.Ai -__-_v_'7 _ O s <br /> D �.. __ $pacdKitbei <br /> rl Pilots I:1 Other �1`r1�D•yIIIOp Q0ISIAIOµfp*-1ftTetI9 3Vi'.,.;_1AMg.— Typo or Trout <br /> Repair <br /> Work <br /> _Appear. Depth a'9Y�ataw.II.I.TVt1Y.t�L7AAdf'IrN�liF1m0�_ <br /> RaWir Work Done U Type of fP M.P. i $leu Work Con"- ] . <br /> Wall Destruction 0 Well Oiamalar Sealing Material g Depth <br /> apth Pillar Nater A Depth •t-' p r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I [NO tspbc system rateml bd it public' <br /> \ l - available within 200 MI.) \ J <br /> installation will ashar Reddens mm <br /> Coa2W_ Other it ( y E! <br /> Number of living units._ umher of bedrooms ��'" T <br /> Character of sell to a depth or 7 feel: _ Wet.,teDa,parch t7 <br /> SEPTIC TANK O Type/Mfg �Olw!� t� CapaeitY� No.CemWArrNl to - d <br /> PKG.TRFATMENT PLT.0✓ Method of DIRODMI <br /> DistanceDistance 10 fragment: Well Foundation Pfoon"Y Lim I <br /> LEACHING LINE No.It Length of lino _ I v Total laoglh/aaa Rest, ;i (� <br /> FILTER BED Ay O Distance to neon: WW J/1 ppgnditlo Property Lim 1 v <br /> o' \ <br /> Aft , a! _ Number <br /> SEEPAGE PITS NI I Depth _ � Slirll__ <br /> jSUMPS r Distance to m t: Wan IQ Property Line/d <br /> t DISPOSAL PONDS O <br /> I hereby unite that I Nun prepared Ihia application and that the work will be pone in accordance with San Joaquin county ordinances.,tau awn,and <br /> rules and regulations of Ins San Joaquin County <br /> Home owmr or licensed Agent••ignatun undies the to,7l—Ing:"I certify that)inIM performance of the work for which Nie permit re issued. I IhNI mit <br /> m <br /> aploY any person In such mW • <br /> ender as to comsublect to workman's coni alion eves or C•lilomis;"Centlecloi t hiring or subcontracting Ugnature <br /> omnillea the foaowbq:"I certify that in tN prlmmanes o the wo k lar whkh-IMMMa permit Is issued,I ami employ pareMa subject to waskman';.eompeP <br /> ana <br /> j tion we of California." i <br /> TN applicant mut cell for W nqukad Inspection,. Complete drawing on reverse aid•. ` <br /> sgrwd ! — nNa:_9!��t �_ Dn.: � 1/.9 L ,&� <br /> I f0 DTMENT USE ONLY 1 E <br /> jApplication Accepted by I Dela -� _ �"' • I 0 1 <br /> Pit Or Grout lnapsctbn by ate_ Final I der 1.00 DY Dat <br /> SAN JOAQUIN COlJN1Y HEALTH VIC® <br /> ;; <br /> Admtloewl Comments: > itli=jltil tE iTl4t lB tt"' •• "ea�aa >Y <br /> Applicant - Return all copies to: San Joaquin County Pujp�JJAc.Eip @ 1 <br /> Environmental Neal tb]le4N; a .NF' E�Ei�l�'lay y <br /> ' end N Ban Joaquin, P YY Ro �^3SlE Z1.t�57O1 !yy¢it <br /> iEE AMOUNT DUE AMOUNT <br /> WITTED�;A _ RECEIVED ay__ DAT[ _. .... _PERMIT:ND... <br /> -- -MPO' -IK I�24µ1aN.Ira al 5 t a 0 t V t7 <br />