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APPLICATION
<br /> SAN .IUAQUIN COUNTY PUBLIC IIBALTII SEIV1SR tf
<br /> b21V I IIONMENTAI. IIEALTII DIVISION 1 i,lD 4
<br /> 445 N SAN .JOAQU I N, PHONE (209)468-'34,20 I ---r---
<br /> P O BOX 2009, STOCKTONt CA 95201
<br /> PERMIT EXI'IIEES 1 YEAR FROM VATF: INSUED' "' "
<br /> (Complorf- :n Triplicate)
<br /> Application is herebi rade to San Cc- rtv f,• . ;.•r:.: '.e conetru,-t aril,. :retail tt.e work herein drscrlb-d. Thio
<br /> application U srd• in crslpltance vlth ;Lr. ::rance Ro. 5-i ann lgome and the Rules and Poguiattone of San
<br /> IJo'atiuinn��C000uu�nty�Publl: Xealth Servlcea.
<br /> co/AA&(, 7G�"�" �'.- s /c-- /.... - ,- ltTe.N�r�j-- ..t er.A;r'•eR! lam,
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<br /> Owner's Name = =-1 _ adn,res ..__. ..-.-_ ----- Phone r7/•._ -�
<br /> Contracts -f✓/, /•'�• �]rraa ' -_ _ .r-u".c ''�'P':oer._L'' T
<br /> TYPE OF WELL/PUMP _— NJAI'AEli . . . DESTRUCTION .'.(>.t of service well D
<br /> PUMP INSTALLATION :-: `,�5'i - k OTHER ; Monitcrlrs Well I,
<br /> DISTANCE T7 NEAREST? SEPTIC TANK SEWEP .f S O,SPOSAL FED. PROP. UNE —
<br /> FOUNDATION __ AGRIL•.I'uRE WELL ,— OTHER WELL PITSISUMPb _
<br /> INTENDED USE TYPE OF WELL PFOBIEM AREA CONSTRUCTION SPECIFICATIONS
<br /> M Ir'justnal D Olen Bottom Mame,a O.* of WPP.E.eawtron—� Da.o/Way Casing
<br /> C Oomest.c/Pnvate 0 Gr"Pack T,Acv T.po or Casing, -- 5
<br /> I' PuDl.c 11 Other Ek,•u DeptI,of Gout Seat _ — T I
<br /> i l"'M.on •_-Aprwo. OoFth Erslom Surface Seat InstlPed tPV.-.�
<br /> Reps.,Work Done U Type of Pump —_. "P __ State Work Done_
<br /> Well Destruction 0 Win Diameter ___._ Sealing Material i Depth AM
<br /> r�Q
<br /> Depth Filler Material i DepthFNV1PGNh!FTAI O
<br /> TYPE OF SEPTIC WORK. NEW INSTALLAT*01., RLPAM'ADDITION DESTRUCTION I tNo septic system�iRfBlypr lF4M�ipeyk.d
<br /> available w,tMn jOdMtlf^r /�7G1SY1(rt�
<br /> 7nstaaatron win serve Resdencs/ Commetaef_ Gls.e•
<br /> Number of kv,ng units: -•!. Number of bw,00ms
<br /> Character of sot'to IT depth of 3 feet: 'hk i mo.,L-/'LIP+ —_ Water table depth _1
<br /> SEPTIC TANK 0 Type/Mfg ys_�f'•I••i'r = _ Capacity J -'Y r.! No.Compsnnw,ts 's
<br /> PKG.TREATMtNT PCT,❑ .�,.r� Method of DisposY
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<br /> Distance to nearest Wen f�� Fo..ndetan Imo' Property Law
<br /> --- - ----i--/I— —"-'_ •tom'
<br /> LEACHING UNE O s No.i Length of line _`1 �J,,ts} _-_— Total lengthlsit* If-- _
<br /> FILTrR BED rl Distance to nearest. Wetl_-i- Fuuncar.on y.� Propertv line
<br /> SEEPAGE PITS 11 Depth Sae. Number
<br /> SUMPS I.1 Distance to neerest. WM�>`'_..� Founda•Kvt �, Property Le-9
<br /> DISPOSAL FONrs ❑
<br /> I hereby candy that I have prepa-ed this applKat o.seed that the wc,k wdr Tie uw+a in iccwiance.,in San Joaquin solani ordinances,state laws.
<br /> rules and regulations of the San_oa0u,n County
<br /> Home owner or licensed agent's sq riatuts candies the follow-ng 'I certdY that,n the pe.lo,mance of Ps work for which this pNnst esissued•I"no
<br /> employ any person,n such manner as to become subpect to"rknyn's compensation laws of Coksofma .Coottactor'f hrrq of sub�conitoctrrq*igttalu,e'
<br /> csnif,ss the following."I unify that,n Ih&performance of the wa►for wnKh this permit Is-"uod 1 anaH employ persons Wblect to wotstnen'e CotrlpenY.
<br /> pion laws of California."
<br /> the applicant sl as for se used inspection* Complete d,awv,g son fir rwse s.de
<br /> Signal% = :L --- - Title !i �l a=-- -- —' Data-
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<br /> FOR DEPAFTMENT USE ONLY
<br /> --S L� �L
<br /> Application Accepted Dr � �'� 'r �! ._ Data-_ ._(... Area
<br /> d �--� 1—ate o rf'
<br /> K M Grout inspection by 'ts�.�L/'�.i6L:Date FmN Inspection br � Data
<br /> Additional Comments
<br /> Appll,ant - Return all ropine to. Son Joaqulb County 3'u!,l tf Health Sr•ra i•'••b
<br /> Eovlroaaenul Hcrith Peril t/Sir vtcrw
<br /> ` •1� <a5 N an .1 utl.• P U hn: 2009, Shin, r"A 95201
<br /> `F 0 AMOUNT DUE AMOUNT REMITTED T RECEIVED aY �^✓'DATE PERMn NO
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