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<br /> ` APPLICATION FOR PERMIT
<br /> SAN JOAQUIN COUNTY PURLIC H.FALTR SERVICES
<br /> ENVIRONMENTAL IIEALTH DIVISION
<br /> �P� I 445 N SAN JOAQUIN, PHONE (209)468-3420
<br /> P O BOX 2009, STOCETON, CA 95201 v
<br /> 7
<br /> _ PERMIT FM!IRSS 1 UAR FRQ11 DATE ISRUTM r ,
<br /> (Complete in Triplicate)
<br /> AwIlit t'.on is hereby sm to San Joaquin County for a peralt to const-uct %aVor Install the work herein deecrtII- This
<br /> aypllcatitm is ssi In capliance with Ban Joaquin Ccunty Ordinance No. 549 andnnnl 62 and the 11rt1ne snd Mttlationr of flan ^t
<br /> Joaquin County Public irti Services. / �
<br /> Job.111. 1`1 Ll 5- 1 C 1 �'� yt� � City � let Biae/Acre►se
<br /> t`
<br /> Name Address S a-u�o tJ� I �!J'�J —b ^
<br /> ri Ovvnsr'sn - r ��+ x;
<br /> 1 ori -�� �. PLS ` 53 9
<br /> Contraclw /y hddreis Ltccnse No, Phone s
<br /> 6/
<br /> TYPE OF WELL!PUMP: NEW WELL O WELL REPI.ACEM�NT Cl DESTRUCTION C1 Out of bcrvlce 11 =
<br /> t — PUMP INSTALLATION O SYSTEM REPAIR C OTHER O Monitorins Wil f7 A:
<br /> " roISTANCE TO NEAREST: SEPTIC TANK SEWER LIN ___ D✓sOP SAL FLD. PROP.LINE 1
<br /> FOUNDATIO'1 ___ AGRICULTUA WELL /OTHER WELL____'_ PITS/SUMP'S i
<br /> INTENnEn USE TY'E OF WELL F'R00LEM AREA t;0 TRI.$ ION SPZCIHCATI(,NS
<br /> O Industrialv+ O Open Bottom O Manteca ON NI E:csystlon Dia,of Well!CaNnp _
<br /> `i fl OOmptk/Prlvaa ❑ Gravel Pack ❑ Tracy Lrpe ct�avnQ---- ,�rcirCitbnf
<br /> i' I'i Public" fa Other n Delta La>th of rout Soal �_' Typo tw Grout __
<br /> skY
<br /> h ,•} I I Irrlpalkart1` -�
<br /> Approx.Osp`.tt I 1 Einem Surfoca SeurlIzTfled by
<br /> Raw Wort Done U Type of rurrrir _ \ Sun Wori Done�r J
<br /> Wr11 Deatruttion' ❑ We*O aRrrtM �✓ 8sa11ttS Nsterial h S>'rptL
<br /> Depth- Tiller Haterial L,aspth_
<br /> •TMP!OF SEPTIC WORK: NEW 1NSTAt L.ATION I I. REPAIR1AD01;'I0N I DIS,nUCTIQ!!I I IN.septic system lam Nted II PuWre Worstis t ,eti
<br /> 1 air I200
<br /> ...?' Irwallation w "ve: Residence v Comnrrciwl__ Other
<br /> in W.rf.
<br /> F lik Lw of W,..p units, — Nu-n:.er of bedrooms \t
<br /> r l' Choracljr W KA t.+a depth of J fast:_._ x —Water
<br /> t llo depth a
<br /> "i SF/TIC TAk% C� Type/AA/p �Yriti r Capacity �- No.Cc,tppttrwrnu Yth
<br /> PXO,TIIFATMENT PLT.O Method of D Y/
<br /> Dirrtance tc nearest: F vtdatwn_I��/ r Cy
<br /> Property
<br /> •i' LTcACaING LIF:Z ❑ No,d Length of lines �V Tcjrsi knpth/eine -,
<br /> FLTEA.160 r❑ Distance to nw.-set: WNI .Foundation ( =.Property Lina ,. .7IF•"�-
<br /> r ;
<br /> ry ,
<br /> k 3EEPAW?ITS It n >
<br /> Depth .z, N mbar
<br /> t - SUfdPE' LI Distance to nt: Wail - '`-Foundation Property Line ,Y /,5.,7 � t�•
<br /> 'DISPOSAL PONDS O T
<br /> c , 1 hsrsFiy terrify that I hove prepared this applicatbn and that the work will be done in sccortiance with San Joaquin county ordinances,state laws,and
<br /> t t 4 ° rulat ti+ol repu4e r>rta if the San Joaquin County .
<br /> He-j,,,pwlyr,or tk,e eed apem's siVoture cwtlrree the 7ollovAnp:"I certify ihrt in the rarformance of the work for which this permit is wusd,i sl,ea not 1
<br /> '�. Sr 'etrtpicy pry person kl rich marwrer u to Letson wbtect to workman's r;ompenaatbn laws o1 Cairv,
<br /> lilornia."Contractors hp a wbtontrrctinp tiLMtwn
<br /> otnMM{i}MIolbelwinq:"I certify"t in the perforrrw cs of the work for which this permit to ms
<br /> Issued.I sho apby poisons ':bfsct to wortmn rHs t Iorrpe
<br /> tion taw's of GAforflla." f
<br /> `7M appiiCaM t,caN Iso d rr,owed ins tvxu. Ca^rtpt+ta drawing on reveres cede. '
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<br /> x / Title: n..u;TL_P./1
<br /> nr, i ,�.�,lrvi.t�h 1 � r.I✓�P PAR?0.:ENT USE ONLY
<br /> X';y`L*Y� Liar✓oeepesd b1' Date Area
<br /> t Inepec{kxt by r Date FMs1?in tion by_. Dsu
<br /> r 1 4 k��i9i: I8 al Convnionts . r..�... t/ ,(�i, I. _,•,„(w,., ,.._ _ S'.,
<br /> _o: San Joaquin County
<br /> Applicnnt - A.rtt.rnall copies to: Sae Joaqul n'Countf Pu b�ic Hsal th Services _
<br /> invlroawntal Health Derml t/Aezrlcas
<br /> 445 N Nan Joaquin, P O Pox 9000, St ,,
<br /> OA 012n1CK -
<br /> x�x �� I
<br /> AMOUNT ME AMWN'r REMITTED
<br /> CASH
<br /> INFO W . DAT[ REKNIT NO. -
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