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APPI.I CAT I O:J SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH r1LV1SION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 P 'EXPIRES 1 YEAR FRA(,Y, .DATE I,,MQED (Complete in 'rriplicat. ) Application In hereby mice to Sen josi County for a peralt to conatruct grid/or Install the work .mein described. This application is seade in ounP11ance with San Josquln County Ordinance Ne. 549 and 1862 and then Puler mA Papulation. or Su, Joaquin County Public Healt. .rYlces. Job Addrma Sc(1Yt1,�P'I_1J_L-- Gry 1_Ge/�'a�� of Size/Acreage Ne-Az _ Owns"a Name _L_` r 1J1. 1�. Advr>v �.rq✓��/ I �x E��J L_�:n _ Pnonal6l,La/.�l�I '�T' int Articles! �„wy�l,-,� 'a s L'cen5tr:N�. P.Odol��ae� � TYPE OF WELL/PUMPNEW WELL 0 WELL REP,A'EMENT r: DESTRUCTION C1 Out of SerYlc. Wall Ll PUMP INSTALLATION C1 SYSTEM RCPAIEI L: OTHER 0 Nonitortng Well O UIS-ANCE TO NEAREST: SEPTIC TANK __ SEWER LINES —__ _ DISPOSAL PLD.___ PROP. LINF. -_ FOUNDATION ___ AGRICULTURE WELL _ __OTHER WELL__._ PITS.SUMPS , INTENDED U:E TYpE OF WELL PROBLEM AREA CONSTRUCTIOrw SPECIFICATIONS n mdustnst U Open bottom C A':mac. Dia.of Well E.t lvehon. _._ Ds of Well Ching EI Onmsstic/Ptivna O GnvN Pick 0 Tuty Tym of Cse.ng_ Specifications; 1'I Public 1 1 Other 11 Balla Depth.1 G,ml Seal ______ Type of Grdut I I bn0.uon _.Apprc.. Ddplh I I '..turn Sudzce Saul Inasllod by__ Repair Work Done LJ Type of Pump H.V. __ Sit WDM Cone___. N _ Well Destruction 0 well Diameter Sealing Nsterial L Depth Q Depth_ Filler Haceetal E Depth__ TYPE OF SEPTIC WORK: NEW In STAUAT10N I I REPAIR/AOOITION' DESTRUCIIOH 1No fepl¢We.m parmined it public srw.r is aysifabl0 wbhir.dCt)faaLl I.,udation will ssrva: Residence Y(I Commercial, U:her „y Numbs,of Inner.,lite:J_ Numhv of bedroom,..�` {�'�: C-s.IJ Ch.racur N sod to•dap,h of 3 to.c.l'....- 041 L/''�. _..._ y�1 _Wet.:tabs depth JLs.c_ SEPTIC TANKNL� 'M Typ•/Mfg _.y_>s Col ncay1'-, Na ComprtmentS A PKG.TREATMENT PLT.0 Method of Disposal Distance Io morme Well Foundation 1rjr- PropM Lica LEACHING LINE tlJ!:-T6 Ne.8 Length of lines Total Ien91h/size FILTER BED fel Counee to nn•rost: Wall__._ Foundation_._ Property Lisle SEEPAGE PITS ? 11 Gain ____Siva_ Number SUMPS LI plain,to,Rauf Wed Founlalion_ . Property Line DISPOSAL PONDS 0 I hereby certify that I neve prepare this opplicslum and that the work will no dons in eccntdance wish San Joaquin county ordinances,alale lawn,and rule,and milwavats of the San Joaquin County Home owner,or Ikeneag silent',egnalma mrtdies the lollowmo:"I mnNY test in the onfomlan s,of the work for which this prriel is issued,I dead not employ•ny pti in such manner as to become subject to wonman i corr.pense•bn law.of California."Connector's hiring or aub<ontractirq signets certifies the Indenting!"I ceniN that in the pdormence of the wo,k for which W.parmll is issued.I shall employ predm evblect to workman's compares. tion laws of C.1wrint.." TM epplkanl Jrloji for•d regmro insp. Iona..Com.l,Z.drawinO.�r� ins,aaidde. / $pard X1..L!_ 1,. s .'� Tilbr�> LC__y(, Dole:,r�— 5 L'+�' �v ,, �1 !',."" reYm�RTMVENT USE ONLY � 1 Application AcrsplwC R' _GQ�.a, _ �- aQ1' IrCTlTy __ Date - Area ©Z Pit or Groin:plpectiun by Data_ Final In:pe'd.n by g s Date Additional comment: Appllcnnt - Return all enplee to: San J..quin County Pubilc Health 9ervlrae / Environmental Health PorNlt/Servlcea 445 N Be. J..qui.. P J boa 2009, Bike. CA 95201 Nf0 AMOUNr OUF AMOUNT aeA1_ CASH R{='L:vlD Sy ;;ATC PERMIT NO wl„ITALY 1, ., s -0 1 �r d ��t9�Z' {M IL]♦