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t APPLICATION tOR VhKVIT T <br /> SAN JOAQUIN COUNTY PUBLIC UALTH SERVICES <br /> FSIVIRONMkHTAL H.LALTE DIVISItart <br /> P O BOX 2009, STOCKTON, CA 65201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES _1—YR FROH__I?ATIJ I SSUM <br /> (Complete iAfn TripllCate) <br /> Apyltettion is hercby meal: W San JoaQuia County for a peralt t-o const--ct and/or IrAUL l the vork bereln Cesc-ibe4 Tile <br /> apylXcatlota is grade 1A ccev1Iance vita 3" Jc qui-s CouzLy Ord,naace No S•9 &^4 1462 "- tte Ruler a.ad Avg%UAtlon,; or Sag <br /> JoaQula Co%Lmty Public lcaltb 84rv;ees <br /> ' Job Add+ew _ �� -- - ,A4L4)- T)A ET. City Lot Site/Acreage <br /> Owner s NAmo Address ZZL &&Z PhOna <br /> Pop A^, 7Tc -7570! <br /> ' -enl,jclx VA&�xR ,11,..' �AId•css L tanks No�"'-��7'k= P'+one �l6gs� 74s`r <br /> TYPE OF WELL/PUMP hEW WELL 0 WELL REPLACEMENT O OESTRLrCTION ❑ Out of Strytt;e Vc.I ❑ <br /> PUMP INSTALLATION ❑ SYSTEM AEPAIR 'I OTHER a4cv,4tar1rK Well <br /> OIST.ANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLO PROP LINE <br /> FOUNDATION AGRICULTUAE WELL OTkEA WELL PITS/SUMPS <br /> ' INTEhOEO USE TYPE OF WELL PAOSLEM AREA CONSTRUCTION SPECIFICATIONS <br /> indwtrral O Open Bottom O F.IantrCa Dia of Well Escavat.On OLA of Weu Caatng <br /> L Oomurrc/Privet• 0 Craw+ Pett Q Tracy Typo of Cas.ng 5gecibcatione <br /> EO P,rb+t !1 Orhar O Delta G4plh of Grout Seat Typo of Grove, t <br /> ntt`e <br /> Cr frn0argn —ADD►ok Depth ❑ Eastern Surface Seaf Inslallad OY y' <br /> Regan Wort Cone U -'Type of Pump H P 5tau Wo►t O <br /> Well Deltnrctton P Wat1 Otarttiavr rr ~ Sealing Aataria.1 i PeptL <br /> ' Depth,Zs .nr} P%Ilor Wtorlal 4 D*Pth � ,- Sao <br /> TYPE OF SEPTIC WORX NEW INSTALLATION ❑ REPAlA/ApOITION C1 DESTRUCTION 0 INo MOMC system permitted if pu3Lc sewyr is <br /> sv.;Ju4 vnlhrn 2200 feet 1 <br /> nstlHatron v..q aen+e Alsrdence Comnsarc a+ Other <br /> 1140F1Numb*f of frvrn9 units Number of bedrooms <br /> CMrictor of soil to a depth of 3 ( t1 Water table depth <br /> SEPTIC TANK ❑ Tyga/?.tfg Capacity 140 Companrr*nts <br /> ' PKG TREATMENT PLT CT Method of Otapoaai <br /> 0%SU A to merest Wall Founder-on Property L" <br /> ' LEACHING LINE 0 No b Length of Innes I Total Iength/uze <br /> FILTER EEC) i 1 Destanee 1�»ai+2st Well Foundation Prooeny Lwu r <br /> M <br /> SEEPAGE PITS 11 L4pth SLts Number <br /> SvMPS LI Dratanca to rraareef Walt FoundeIrvn Property Luse <br /> DISPOSAL PONOS 0 <br /> I Mreby codify that I have p•eparvl this appliest*n and chat the wort wrtl be dons to sccor4ance with San Joaquin courty ordinances sate tawyl e'+d <br /> rube and regulerronl of the Sin Joaquin County <br /> MOM$ Owns►or Ircansad agent a &gnarure cond.as RV I-jrlow ng I certify?hat In the per1c frnance of the wort for %4^ch th+s porrmt u rt..fuvd I I.S.&V nor <br /> Im+ploy any person rn wch rnam"I as to becoms wbrect to wortrran s comoersatron Laws of ClAfprru Co'lttactor a hrr.ng or tut>conlractrng s+gna+ure <br /> certifies tM fortowrng I Cefafy that In the partotrn8nce of the work for waa <br /> h.ch this p4vmt is ruej I t'�erl employ persona ayb,ecT to Mrprkrnirt I corr,7anta <br /> ,tion tam of ulforr" <br /> he Applicant errGst WII ro•rll requ Jsrf uniDV.1jors Compere drewng Ort revers* 34 <br /> -g nod X Tala _ Date <br /> rOA DEPARTMENT USE ONLY <br /> Application Accapt*d by -- ,• _ - - — -, Date Arae <br /> rt <br /> io"'l)A, <br /> ut Inspection by Otte Ftnal Inspacbon by pat* <br /> Comments _ <br /> �PPllcaat - Return LU copies to SlN JOAQUIN C•OLNTY PUBLIC XXALLTU BEAVICYS <br /> EWIRO WEXrAL IfEALTV DIVISION PLUIT/3EAVICa3 <br /> 445 N SAIL JOAQUIN. P 0 AUX 2009, Yrt)CXTON. CA 95701 <br /> ' rNfG AMOvNT Ovf AMOVrti• 1tfUiT7f0 CK <br /> RE[Eryto Pr :0ATf PEANUT Hp <br /> v}N irty •r•ar <br />