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v4 �,•� APPLICATION FOR PfililiXT SAN JOAQUIN COEJNTY PUBLIC HEALTH ERVICES r �- i 1UV ENVIRONMENTAL HEALTH AIMS I 445 N SAN JOAQUIN, PHONE (209)" P O BOX 2009, STOCKT'JN, CA }y y 3 5� Complete in Trip)-icland i� 7 , the wart h�Dt�tr"C erihed.. 'Phis'' Application iv herrSy made,to San Joaquin County for n permit to s-onetruct the Rules and Re6ukt application is made in compliance with Sen Joaquin County Ord!rance No. 949 ��,• (' Joaquin County P;hlic Health Servsy�s. 'City Lot site/Acreage 1 Job Address . - A✓/+ //Q� •�'•'� �^ Phone ...-.- •. Address Owner's N►me Phone � +1 Conlfactor Address-L-e- WELL REPLACE ENT l� _DESTRUCTION p out or Serv1N.Y�e�' ❑ torf NEW WELL - Qbni rg (;] o P M P: - F WELL! U 7Y.E O SYSTEM R AIR ❑, OTHER ❑ PUMP INSTALLATION C} DISTAIJCE TO NEAREST: SEPTIC TANK SEWER LINES DEAL'PLO. _ PREP.LINE FOUNi7ATION AGRICULTURE WELL OTHER WELL PITS[SumPS ` INTENDED USE TYPE OF WELL PRbBLEM AREA CON TION SPECIFICATIONS Bontxn > ❑Mar tau of eH c-xctvation DIB.u}Vysll Casingt Ci Indwtrisl ❑Open. ., : Specifications: -- a Type,of OomeuiclPriveta ❑Gravel Peek, ❑Tregy Type dI Cesinp i')Publk'. I:1 OttteS, ""' n Delta'' Dbpth !Grout Seal �--- i.lefityatian �.._Apnros. Depth I I East Surf Seal tnstslbd by j I p :! M.P. State Wark,Done T of urnp . II a Wok Gone 13 vne th Repair . ... Sealing Material b Rep - L4fsIP Disn+ster•:�-�-- '' _ ' WsN Deetnettion ❑ Tiller Mft�1; 1*) Doth ' Depth , 'PE. DF SET1IC WORK; ,NEW 3N57AL .7 ON i I REPAIRIADDITIoTRUCTiON �� r`w trim r200 lest`1 ?f P. r, Instetfation wiq sArve: Residence,.� CommerCiat thar// t " i Numhef of bedroorru l 1-�{ r f3 JII s Number of littng units; �_ Water tabN depth f Chatocter Waco to a depth of S feet: Na.Cotnpartntants (� SEPTIC.TAW. ❑ .Typrallvtfp LL Cepacityr \j Method of Dnpoa++1 PI(f3.tREATMtENT PLT.❑ a V' o7lC Dlstarrce to rwereat:. Well urtdetion PrcP+rtY Lina dfifG ' � I "T r I ienpthlaise 0- LEACHING LINE ❑ No >� Length of liras Q ounda[ion P[opelty Lina r z•' FILTER EEO ❑ tta t6 rtasnst:. .well -; 1 r1 3 Sire N 5EEPAGf PITS l l Wpth t} property Lina SUMPS LI Drstanco to MWO%Se: Well undaion DISPOSAL PONDS '§ ❑ J[/ ` `;I DISPOSherobv AL POitv that I>have Prepared this epptrcetion andrMrf the vrork will be don*in accordance with San Joaquin county ordinances slate taws and e rotas ar; ,reguistitm 6f the San Joaquin County d t .Hama ownsr.,M titar4teY1 agent's signaturo cartiTfaa the foeowing:"1 ce"ity that in the performance of the work for which INS psrmit'it iuusd,'l dtiWl rat' r >,ntpiov any Person in such manner ae to become subject To workman's compenaat on taw s cf.CaliforrHa."Contractors hioub or soh G tkir a n's aiQnature 3 ' " seftili Sha fo6ow+ng:"'f Cordly that IAtho WtWmernce of the work for which this""nit is issued,I stall etnPW persona subjaet to workrrten a eompenaa- l 4 don I%"of Cdt6orrio. ! - l 5 The appficant t caH fa Ins; <tionr.ComWetednwing on reverse sKie t r Title: &L-< A Date: -L•- Signed X. FOR DEPARTMENT USE"'ONLY Date Area Appllwtlon Aeeopted by / Date Final Inepaction by dr Data" Pit or Grout Inepactior.by AddhIc"I Cornmonia: o,5 .- I yf :rrr -Nr✓ "' ." Applierint - Return all conies to: sen Joaquin County Public Health Servicea y. r I- Bnviroamental Health Permit/Seraicea f�/77` I(� �1d7 '� 449 N San Joaquin, P 0 Box"7009, Stkn; CA-952011. -- F.. tC RECEIVED aY ' DATE ►EIl1NN.'No. -- FEE �UjWAMOVNT AEMITTED f i INFO CASH '. En I>`R SRN f R 1 f {'i - . ... .4a 4 .i • ^_ _ -.. .% ..., u ...- }.... n...n . �}.-.H,.:...,r]! M � kc.4: '. — ./