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t� APPLICATION FOR PERMIT v <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 0 <br /> ENVIROAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-8420 � �Pe T <br /> P Q BOX 2009, STOCKTON, CA 95201 VeD <br /> IMIT FROM DgTS T 4 ctttssn L�'(CJHEQl/1 Cdr^� <br /> (Complete in Triplicate) O,y�; q(ry ,�t,�Ivey <br /> Applic4tion is beseby Vale to Son J �NTq -3arrif 'rS <br /> syplicatiou Is Vale in Joaquin County for a peralt to construct and/or install the work here n�deicri <br /> Joaquin County public 8 use V1th San Joaquin county Ordinance no. 549 and 1862 and the Rules hod Re is <br /> Services. y <br /> f�a•.Ir;J�,� us �O Al- �(� Solations of <br /> Job Address R/ 17 /t/ G4r+r � 4+ eage <br /> � Q AyQ City T Lot size/Acreage <br /> Owner's Nam. Ack> v, U--.'44 9J'noef o,I/ 1932.//. el P.--I Q.+'— <br /> address Pnort. q V _y 0 <br /> Contractor Wayne oedl - P.O. Solo 726 LL <br /> �• Address 1..1 nt�,lC A 954A License No.3--7`3y5 ph 91)445-?3S$' <br /> TYPE OF WELL/PUMP; NEW WELL D <br /> WELL REPLACEMENT D <br /> PUMP INSTALLATION O DESTRUCTION ❑ Out of Service Well <br /> SYSTEM REPAIR O 5'1 "t OTHER X Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1jea <br /> FOUNDATION -�=-�_. AGRICULTURE WELL --'—�— s <br /> OTHER WELL/�Ydi PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl I+tduat isotic O Gr at► O ray Dia. of��nion <br /> O Dermatic/Private O Growl Psdc Dis. of Well Caslrg <br /> ('I Public n Other n Delta Type o a Specifications <br /> I I Irrigation Depth of Grout Seal Type of Grout <br /> Approx. Depth 1 I Eastern Surface Seat Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Wel Desnuetan O Well Diameter 8441108 lfaterial i Depth stat.work Done <br /> Depth lines MsterUa A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION I I INV septic system <br /> permitted if public sewer is <br /> Installation will saw: R available within 200 feet.) <br /> Residence_,•,_ Cottrrnerclel._ 'Other <br /> Number of living units: Number of bedrooms <br /> Character of Vol to a depth of 3 feet: <br /> SEPTIC TANK- O Type/Mfg Water noble depth <br /> PKG. TREATMENT PLT.O Capacity No. Co of D <br /> Distance to newest: Wo* Foundation of Disposal <br /> Property Line .� <br /> LEACHING UNE O No.&Length of lines, <br /> FILTER BEDD p tom: WON Total length/size C <br /> Foundation Property Line <br /> SEEPAGE PITS 1 1 Depth Sise . <br /> Number <br /> SUMPS <br /> LI Distance to newest: Wel Foundation <br /> DISPOSAL PONDS O Property Lala <br /> I hereby csndy that i haw prepared this application sed out the work will be done in accordance with San <br /> rules and regulations of the San Joaquin County Joaquin county ordinances, state laws, and <br /> Homo owns►Or laataed apant's signaWre owtifiss the following: 1•1 certify that in the performance of the work for which this permit is issued,t,hal not <br /> employ M @or-N such nwraner as to boom"subject to workman's compensation laws of Cellfornia.,,Contractor's hiring or sub•contrectirg signature <br /> 6011 of Calfornta.h Certify OW in the of the work for which this permit is issued,1 shah employ persons subject to workman's eortnpensa- <br /> The applicant mus4., <br /> lip niquirvedoo4pqedons. Complete drawing on reverse side. <br /> Signed ; OWNER/PR T ,C'T COORDTIvtR Date: 7/10/91 <br /> V <br /> USE ONLY <br /> Application Accepted byA= - <br /> Date <br /> Ph or Grout Inspection by Date Q- / <br /> Final Inspection bE <br /> Datsl7_ �— <br /> AdditiorW Cortxrrnte: <br /> Appliceat - Return all copies to: 81113 Joeevia County public Smith <br /> Services, mriromental Health permit/Services <br /> 1601 Z. Baselten Ave.. P 0 Hoc 2009. Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT]R�REM•ITTED CASH RECEIVED ev DATE PERMIT NO. <br /> EN,171 IRE/.„a 5► <br /> i' • I/ <br /> EN i1•Za <br />