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SAN JOAQUIN COUNTY PUBLIC HbeTN SERVICES <br /> I <br /> .tUiVIR0NMENTAL HEALTH DIVISION <br /> � 445 !7 SAN JOAQUIN, PHONE (209)408-3420 <br /> j P 0 BOK 2009, ST_OCKT0N, CA 95201 <br /> P- LIT EXPIRES 1 YEAR FROM DAT- M12M <br /> (Complete in Triplicate) <br /> Appllestto, is Mreby emde,te Sao Jo iv county for a ytrut to construct and/or sna all the work herein described. This <br /> an"llnsit= la meds In compliance with Ben Josqutn County Ordlrunce sio. 5L9 and 1562 s.M the Rules and uleRea SulationOf San <br /> Jceulutn Count <br /> y <br /> Nblic Health Services. <br /> .lob Address J L�L�— A�!P e L Y 1 6/T Y C'•v��w�.Y�/ 1Q°t ilio/A<rew6rt <br /> �l� 4/�- 8��C, TaTffa�f PnarwJ <br /> �Owmr'e Nam. �a�L�% NJes OCalteTs _ <br /> AEEress___------_Lrcen:e No. PrnrM <br /> Lonvacla Y <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION l t of -tarlee Vell <br /> OT HFP !wn_tor St0 W11111 I� <br /> P'JMP INSTALLATION 0 SYSTEM REPAIR 0 CQryct esw N A�ItJ <br /> DIST!NCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD.__ PROP. U E _ <br /> f0UN0ATI0N __. AGRICULTURE WELL __ OTHER WELL--- PITS/SUMPS <br /> INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IM..w.l O Opan Bortom 0 Manua Dia. of Wad frteyatiaa 04.of Wag Cuing n <br /> Type of Came Spscilkakana V <br /> EI Darretkl PrMu 0 OtherG1410 Pack 0 Tracy g-- Type of Grom <br /> Il Pudk ❑DIMr fT Delta Depth of Groin Sesl -- Q <br /> I I I";'~ ._Apryoa. Depth 1 I Euurn Sudaca Seal Installed by <br /> RW Work Done 0 Type of Fump N.P. State Vvoi,Dora_ <br /> Sea1LM wterisl A Depth <br /> Well Destruction 0 We"Diameter rillar IYur1s1 E Depth <br /> Depth <br /> { TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 PEPAIR/ADDITION DESTRUCTION i �',I�vnSystem�'mal.) d PrWc ww'er,m <br /> fIMISAalion will aha: Rssklence_ COrR M'cW_ Other <br /> ]' Number of living wnna:__. Number of badroome <br /> f` Character,or NA tv a eklib of T test: Wtler team,depth <br /> SEPTIC TANK LJ Type(Mig CaWciry___ No.Comartrnanu <br /> S PKG.TREATMENT Pit.0 - Method of DiapvalHis <br /> y Distance to fissio : Well Foundnbn Property Lir <br /> LEACHING LINE ❑ No.b Length of Imes Total length/airs <br /> FILTER BED 0 Distance to Mama Well Fou"SITOM Property Line <br /> SEEPAGE PITS I 1 DdPlh <br /> SiN Number <br /> 1 SUMPS LI Distance to name Was_ Foundation _ Properry Line <br /> DISPOSAL PONDS O <br /> sista lamas, and <br /> I M,sby asrtRY that I Mve prepared this appikatkn cnd That the work will be done in accordance with San JOIKI county Of inancu, , <br /> MMS and feguhlfona of the San Joaquin County <br /> Ho"ower w Ikariad agent',Signature cen.fles-he agowing:"I certify that In the performance of the work for which this permt K He -1 shat"Of <br /> employ any person h much msnnar a to become aubpct to workm,n's comper alion Ove of California."Contractoes hbhtg N Sub Contracting sigr it urs <br /> _ certifies the following:"I certify that in the pAotmana of the work lar which this armit is issued,I eMIT employ pauom sublect to wohmei a COMWU- <br /> tion Lewis of CSIHOM1.11 <br /> RPplkarrr))yfrttt must uE for Y! Ins &ms. Complete drawing ori rererss Side. <br /> ppEe"FG 9Y// � Dart: <br /> j Dart: �¢-- <br /> Signed 77'aT( 2 i-� _ Title: <br /> r� F R DEPAPTMENT USE ONLY �'' <br /> Am--!;�12_ <br /> Application Accepted by 161( - Date_L <br /> IN er Omut bTapactlon by <br /> Data Final Inspection by <br /> Additional CaRm,nu: <br /> Applicant - Return all copies to: San Jaagala County Public Health Services <br /> environmental Health Permit/eervl.ee <br /> - ee5 N San Joaquin, P D Boa 2009, Bike, CA 95201 <br /> IEE AMOUNT DUE AMOUHf RfMIRED RECEIVED BY DA IERMITfW. <br /> NFO /7 <br /> �� � ✓�_ / - <br /> F«Hs <br /> Y3 <br />