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APPLICATION FOR PEPUdIT <br /> SAN JOAQUIN COUNTY PUBLIC SBALTH SERVICES <br /> ENV I RONUENTAL f3EALTH DIVISION <br /> P 0 BOX 2009 , 'STOC%TON, CA 95201 r1L <br /> (209) 48$— 3420 <br /> _ F <br /> YEAR ZROld D <br /> (Complete In Tr!plicate) <br /> 4ppllcaci°n Is madhere <br /> made (Complete <br /> Sazi Joaquin County fora � <br /> +pPt-.cacioo la tsade in Cc�11ance vith stn 3 permit to ceila,constru54 ant!/or lnetnl: thu vork herein described. This <br /> County Public Health services, Joaquin County Ordinance Ho. 549 and 1862 and the Rul <br /> (, `d Regulstlans Of sun <br /> %C7 Acores: ` 3S- 4Jt7- /$f <br /> (Y�� j� City Lot Size/A'creaga IIZ <br /> �xnar't Name Address ax, &a <br /> _. ,actorTEG <br /> Address Po.ALI,< /6LJ8d <br /> '- -e�-'�•t 'S�� _ L c e n s e No. 568 `i r <br /> 7F WELL/PUMP: NEW WELL ❑ none <br /> WELL REPLACEMENT 0 DESTRUCTION Out of Se <br /> PUMP INSTALLATION ❑ rv:cc v at-1 0 <br /> SYSTEM AEPasH 7OTHER 0' Mtontcoring Vcj1 <br /> ANC"c TO NEAREST: SEPTIC TANK S SEWER LINES /O • 1510// p/b6cs C.7 <br /> FOUNDATION _ DISPOSAL FLI)46:t¢ PROP. LINE <br /> - AGRICULTURE WELL <br /> _/� OTHER WELL /O • PITS/SUMPS <br /> NTENOEO USE TYPE OF WELL PR08LEMAREA . <br /> CONSTRUCTION SPECIFICATIONS <br /> .7 1n CUslri ti —•�--- <br /> ,/ ❑ Open Batton' ❑ frlantecaOia. of Walt Excavation " ' <br /> ''.�ComarticlPrwatc . Dia. of Well <br /> Casing <br /> 0 Gravel Pack <br /> ❑ Tract <br /> Y Type of Casing v/JG � 5pecilicaugns <br /> hi'Othor ❑ paha <br /> 1L Depth OI Grout Seal ✓� ,fr1. C.•—_' Tyoe or Grout r7 r <br /> - `�•`f6�on 1Aptsrox. Depth ❑ Eastern -yam <br /> Surfaca Saw Instailva OV _J L <br /> =.oca�r '>vort Dona U Type of Pump <br /> --�--�_ H.P. $sore Work Oona <br /> ^'ail Oastructian C Well Diameter Seating M4terlal G Depth <br /> Depth Piller Material S Depth _ <br /> YP_ OF ScPTIC WORK: NEW INSTALLATION t- R'PAI Rl kbOlT10N cl DESTRUCTION C1 tNo saptie system permitted it DUDIiC sewer is <br /> tnsllllaticn will serve: RasidenCr, COmmareiaf_� Other available ws[hin 200 faet,l <br /> ,Numoar of living uAlta: Number of bedrooms <br /> Chiractar of sail to a depth of J real: <br />�s?TMC TANK ❑ Type/Mfg --Water taola down ` <br />'Xu. TREATMENTCapacity— No. Componmanta <br /> PLT, � k <br /> r Distance to nearest: WallMethod of Dtaposal <br /> Foundation Property Liner <br />.-AC:nINC LINE C1 No. S Length at linos <br /> 'LTcA a E 0 Total langtn/size <br /> n Distance to nearest: Well FOun,_+auon <br /> Proorany Line <br /> SEEPAGE PITS I 1 Depth <br /> 5sra ; Number <br /> 7UMPS LI (741ance to nearest: Wali ��_ 3 <br />'ISPOSAL PONDS Foundaiion. Property Line t <br /> -eruoy Certify Snat I have <br /> prepared this application and Thal the work will be done in aCc.ro4nta w,th San JaaQuin county asdrnancns, state laws, ants , <br /> ;las sno ragvlativns of the San Joaquin County <br />�crna owner Or licensed agant's signature canifias the following: "I cattily that in the periormanca of the work for which this permit is �ssueq. I shell nal <br />="3'asoy sny oarson in such rrannar as to become aubjaCT 10 workman's compensation laws:,r California." Contractor's hiringa <br />:ar`ilies the following: "I cattily that in she r't0rmanCr of the work for which this armit it'iaaueal I shall C to of sub•contracung signytvra 1 <br />:'" taws Of California." D <br /> P Y Dafs°nL subject t0 workman's-compania• <br /> The appticant t Ca [ r all to tilted ins <br /> pe,CSloni. Complete drawing ori rwefa0 side. - <br /> iifnaq <br /> Tige: y <br /> Dara: <br /> R DEPARTMENT USE ONLY <br />�DDIrU tion cCaoted by �/ <br /> Araa <br /> or Grout lnro+ction by gats <br /> Date Final Inspaction oy Date <br />•Coitional Commence: — <br />•r^p'-_c.L^,t - Ae LtzrO all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH 3ERVICI•.•S <br /> FNVIRODUZNTAL HEALTH DIVISION PEASfIT/SE1iV10ES <br /> 44S N 3AN JOAQUIN, P 0 BOX 3009, STOCKTON, CA 95201 <br /> FEE AMOUNT RUE <br /> INFO AMOUNT REMITTED RFGEtr;ED By f <br /> _ CASH DATE I PfRMtT NO. <br />