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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 99201 <br /> (209) 468-3447 <br /> PERMIT $r.(1I RSS 1 YEAR PA �� � <br /> (Complete in Trlplic �t�✓ J +' <br /> �ff� ^ <br /> P <br /> Application is hereby arde to sous Joaquin County for . perttlt to construct and/ 9 <br /> th/ orY beret. described. This <br /> kpPll Catien Is rd. in Coopltanca with San Joaquin Ccunty Ordinance No. 549 and 186E .' Y4 sae R.NLt1on. of Ban <br /> JO"ule County Public Heath fle'trrl<e.. -,(/-� <br /> .100 Addtu City <br /> r ��t <br /> (�[Q/v/nx(f1 �x <br /> �}NQ. �(O�t c" Addrescl� e2 J��pP�l�an •. <br /> 'I.enn CTI& - '- fess r It ense No. i�(.SL PhorN } <br /> v TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION Ci Out of Berrie Well Cl <br /> PUMP INSTALLATIO* SYSTEM REPAIR ❑ OTHER ❑ Menitoring Well CT <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES _ DISPOSAL fLD._ PROP.LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS rt <br /> E. NTENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Indawnal ❑open Bonom ❑Maniacs Dia. of WEN E¢w6lgn Ob.Of WON CaWrp <br /> T .ppmeatk/private ❑GnvM Pack. ❑Ttacy T"01 Cawng Bpac1lkatkM <br /> �. ❑Puoic (71 Other ❑Delta Depth of Grout Seal Type of Grout E <br /> M Inertion _Appro.. Depth C�1 EECwn Sudica Sew Installed OV T!` u <br /> ✓ 0 <br /> Ropsfr Work Don U Type of Pump H.P. <br /> State er _ <br /> WE9 Destruction ❑ WeN OWnet // Bean M4•wrial d DeptO CifEQ k <br /> 7, Orpth Piller Material A Depth <br /> E <br /> ? Tvpf OF SEPTIC WORK: NEW INSTALLATION il REPAIR rAODITIUN❑ DESTRUCTION U INs able thin 2 fast.I M prOkC s.war b <br /> t 4wdaDN thin 300 1..61 <br /> 1 1ntaNbUott win t : R"iderwe__ Commenist_ Other O -� <br /> [ Number of Yviny units:_ Nuri of bed'OO-1 (� <br /> j ChrKNr Of eek to a dapih of 3 feet: Wain table depth lU <br /> BE►TIC TANK ❑ Type/Mfg Capacity No.Comynmonn <br /> PKG.TREATMENT KT.❑ Method of Disposal <br /> Dbw"e to"slut: Wen Foundation Property Lin <br /> ( LEACHING LINE 0 No.A Length of lines Total length/sits <br /> FILTER$ED ❑ Distance to Maleic Will. Foundation Property Line <br /> S SEEPAGE PITS I I Depth Sit Numper <br /> fSUMPS LI Divan a to 1eeree6 Well Fou 4siort Property Lkw <br /> ` DISPOSAL PONDS ❑ <br /> FF, I"retry C1, tNI I hm wepstse:lis epOicnipn and that the work will 0e done in accordant.iv th San Joaquin county oro)nnces.Star*Whiff.find(I��� <br /> S rulaa and tgulalibra of the Ban Joaquin County \,W. <br /> j31 HO"ewer Of licensed 89411"1;0-41-16 call IM following:"I C.ndv the In the p.dwrwnce of the work for wTkh this paint it blued,1 sMN her <br /> .mploy enY perwn N 4u<h mannr as to become wOMet tp wrkman'a<empenuhon 4w4 el bld0rnia."Cbnttctore hiring or WbeonuactMg elgnaiure <br /> cenllles the 1011ewil4:'9 penily that in the pedrininI.1 the work for which twit permit is issued.I.hall Employ perw-a subject to wprkman'4<ORgenY• <br /> o tion ler,of DWlorr.:a," <br /> The appiken: c6N ler recruit"inswfio-s. Orn Of'dfs ing 0n ewe tile. <br /> R�Yy <br /> Bq E��� n P/7/ /3 �_ Tea: wte: <br /> ti FOR DEPARTMENT USE ONLY <br /> Aree All <br /> ApplkEtlon Accwtd 67 <br /> DY --_-----�!� Gate�—•�� <br /> Pit r Grout I"pettan W Date _ Final Inspection Dy���5� -_----1!1— g' <br /> AddnorW Convi sesta: <br /> .'}E ApPllmt - Not— aLl COPS-- to: BAR JOAOUIN COUNTY PUBLIC HRALTH SERVICES <br /> -Q RIVIRONY:IITAL NNALTH DIVIOf ON PBeM1T/SERVICES , <br /> S; 445 N BAN JOAgUIN, P O BO][ 2009, STIKOtTOfN, CA 95201 <br /> i FEf AMOUNT OUE AMCVNT RFwTTFO CASH RECENEO BY DATE PERMIT NO. <br /> V INGO � <br />