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t <br /> APPLICATION }OR P51A4IT <br /> • t SAN JOAQUIN COUNTY PUBLIC ILEALTH SERVICES <br /> ENVIRONWENTAL HEALTH DIVISION <br /> P O BOX 2009, STOC:KTON, CA 93201 <br /> (209) 468-3947 <br /> (Complete in Triplicate) <br /> ` - Applica.lon is hereby Pia4e to Sa.p Joaqutn Count,, for a permlt to construkt and/or Install the vc-k berein described Thls <br /> application is made in eoeE.l.ance v .h San Joaquin County Ordinance No 549 and 1962 and the Rule• and Aagmiations of San <br /> Joaquin County Nblie 9eilth heryieea <br /> V Job Address _rV/�h. y� ._1[�r1v.c ��j Lot <br /> �rS,Boat/Acreage�q <br /> _e_ owner a N....- �/!/l I r v-' AOdresi �` IVC1L� -E ! V (�lK /O Tj PhDns [ <br /> 45&0e\czA-ST C--5 (A� <br /> rr7$_actor L�l4TLl1h cPLLR _ Aearrts n 1717-11 lR(s G OWZI4 1 L cense No :15 C"507- <br /> TYPE CF WELLIPUMP qEW NELL C WELL PEPLACEMENT f_3 DESTRULTION O Out or Service Well L) <br /> ~ _ PUMP INSTALLATION C SYSTEM REPAIR {7 OThER ❑ MonlLorin: .?ell <br /> DISTANCE TO NEAREST SEPTIC TANK 70 SEwEA LINES DISPOSAL FLDii 'PROP LINE <br /> _ FOUIDATION .lL— AGRICULTURE WELL OTHER WELL ��b" PITS'S„MPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z11 <br /> ` r ❑Industrial D OFon Bottom L7 Manteca D.■ or Wei,EaG•Yal.On Dia of Well Cas,n <br /> U Domestic?FMAte 0 Grovel Pack 0 Tracy Type of Casing ✓e, Svcd,cNrons y� <br /> c M Piiblrc Depth of G+ovt Seal e TYps �f Grrw�:L <br /> f <br /> G trr..atron /�AOproa Depth O Enle-'+ Svriaca Sa•I Inslais•d by <br /> Repair Work D-ime 0 Type of Pump �74'ZG H P Si to Work Done ` <br /> W E+eet ctwn Walt Drs•Nolol r Sealir� latnrlal It Depth <br /> ' a1t.1'ref' i� Depth c Til..er 14tarlrl i Dept'lif <br /> TYPE OF SEPTIC WORK NEW.NSTALLAI ION 13 R,PA1RIADDITION CI DESTRUG ION CJ lNo aephc syal•m permrtfed d public sewer is <br /> f svartabte within'OQ Joel I v <br /> Insnitatron will alive Rei•dence_ CDrnmefcul_ Other \� <br /> Nur be, of Irving units __ Numbor of bedrooms A <br /> s Charomw of tori to a depth of 3 tWater tablo depth <br /> i SEPTIC TANK ❑ TlpalMlp Y sty No Comparen+ents <br /> r PKG TREATMENT PLT U Method of Disposal •' <br /> { Dittrr.ce to nearestundehpn Property L.ry \TI <br /> ` - LEACHING UNE CI No 6 Length of hnos Total length/size <br /> ` I FILTER BED El Dolance 10 nearert Well Foundst.on � Pfoporty Line 1 <br /> SEEPAGE PITS 11 Depth S Numbe <br /> SUMPS LI O.sunce to nearest all,._„�,�, Fouri.folion Props Lr�e <br /> DISPOSAL PONDS O <br /> 1 hersby comily What 1 have p,e Dared this appl-Cat.on and that the work wdl be done in ac Coidameq with San Jospvin county ordinances elate lawn and <br /> D1es and f•gulat.oris of the San JO•oom Cou-ty <br /> 1 Home owrer Or I,een"d agent s signatvr•demi•1 Ine IC00-,g I Cen,fy tAat in the perlormanCe Of The work for which 1hrS pafmrl ra.uveal I shall not <br /> j employ eny parson in such''pane'at 10 I»[Ome luhfeCt to workmen s compenssuor laws of Cel IOrnH Cont,sclof a h.nng or cub COnIraCUng s,gnature <br /> i Cerhfwl 1M Following I Certify ih.t on the prrfofmanc■0 the wcrk for wt-on this permit is iarued I shall employ persons sutgoct to workman a�ornpsnaa <br /> tion laws of CNrfornls <br /> i The applicant rtw ail for�eft r r•d tnspecrana Comprete drew.nq on reveiaai r tle' -�a <br /> jig nod Isla .. � Date <br /> } FOR DEPART►.»ENT USE ONLY <br /> APpi•catron Accopi@4 by .L "f Data._._,_ Ara* <br /> Pit Of Grout Inspoclnn by Dole Fin•<Inspect on Dns <br /> AddnEOnsi COmr nla <br /> A7,llceat - Return all copies to 'A.X JOAQUIN COUNTY PU9L'C HEILTA SERYICES <br /> ! Ir+t1H0HYF_NTAL HEALTH I1IVI9ILft? PLRUIT/S£NVICES <br /> 445 h Stitt JOAQVIH P O aitlE 2009, 7TUCKTON CA 95201 <br /> I lrEt AifOL,h' OUi aMOLN11 REMITTI CASH RECLIVED 0Y DAIE I PIRr.11T NO <br /> EK tltr tel,, ,..t.} � —G`� � V � ��' 'i�/1J 1�J � (^•� <br /> I•i e�a `I � <br /> Munn= <br />