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AI.PLICATION �-- <br /> SAN JOAQUIN CCUNTY PUBLIC USALTN S IMU f� � <br /> N ENVIRONAENTAL HEALTH DIVISIO " <br /> s, was 445 N SAN JOA^UIN, PHONE (209)46 {�p�y <br /> P O BOX 2009, STOCKTON, CA 95 O Hl� ti f <br /> T <br /> (Complete In Triplicate) <br /> ~ w a <br /> Application in 'teretr/ made to Sac Joaquin County for a permit to ennatruct and/or 1 stnl,.l the wort herein described Thla [ <br /> application is e+ade In cae>plSance vith San Joaquin county 0 dSlence No 54-9 and 1862 and the Rules and AeXuletlona of San , <br /> J'oriquin County Public Health Bar Sere <br /> r - <br /> !11J t b'sr/Acrewgr <br /> Job Address �' C"', � <br /> tl :^•:yrs r` O�wner a Nam�e,,,^lAc3d�E,l/S'� l tl(�+��j/�, , <br /> 10� <br /> Comracttx � d =eer +L[crnseNo none_ <br /> Sar <br /> TYPE OF WELL/PVNP NEW WELL C] r W L REPLACEI.IENT f7 DESTRUCTION Ll out of rierrice Well r <br /> .XP PEC%. 0., ,SYSTEM REPAIR L� OTHER 0IfenStorittd Well <br /> PIJ'+tP INSTALLATION t <br /> D STANCE TO NEAREST SVPTtC TANK SEWER LINES DISPOSAL FLD PROP LINE <br /> ` m =OUNDATION AGRICULTURi WELL DTHER WELL PITSISUMPS <br /> TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IN <br /> C7 Indusviat O Open Z3onem ❑ 4 SAItica Du of W 11 Escsratron Du of Walk Caainp <br /> .�,,"" DomesnclPrivatt 0 Gravel Pack L3 Tracy type of Casino- 5peufKaGo*i a <br /> f., yyJ I 1 Public I 1 Dthor 171Det[a Death of G�oue Seal Type of Groot t <br /> I In IRin w.Aprvoa Depth I 1 1 Easurn fI Sirtace SaYt Insiafled tW t <br /> h.�� � F1 , FSepaw Weirtr Done LJ Type of Pump a H P __I _.__.._._ 5ta}tt Work D <br /> i^ k� ', 5ea11rs FlattrSel i Depth <br /> Won <br /> Weft O"tn,cticr+ O WeR Demeter r 1 t J <br /> Depth Filler Material Depth <br /> - �-- <br />#' _TYPE OF SEPTIC WORK NEW INSTALLATION i i HEAAIRI.SD`J[717111 I LtaTRl1GTION I I INo Nprrc/velem pNmrlted�f pt,bhc wlwer n 1 <br /> avaeUbN within 200 loot I <br /> "r, Ir.psltatrn wAt <br /> se" Residence Cpmrrerciel _ 011ier (* <br /> 4, 4 t r t1] <br /> ",rNumbfe of Fvr=+p un=ta Number of t»droom! I " <br /> of UA to a depth of 3 feat AY� <br /> SEPTIC TANK'S O Typo/MfgCspanty E VMO _ d <br /> r PKG_TREATMENT PLT 0 , R nal — <br /> Distance to nearest Well_ Fnundatron Prgq�rjy LZ-49-19Q�_ I � Q <br /> Torst�, J43'frJt1L11 � `+,"' <br /> }fa �j_ �;• `LfACHINC LINE C!' 'No a Le bth of lines FU LIM <br /> FILTER SED C7 Distance to nwarast Wen Founaatwn _ a <br /> k. <br />' ln,�S i i` SEEPAGE PITS 11 C.epth S" Numhwr <br /> 3 - <br /> ;n.,� �s "} Y SUMPS_ ' L1 Datanu to nearest wee fcunhstwn Prc-,erty Lino ` <br /> DISPOSAL PONDS 0 <br /> i handy,Nnrfy that I have prepared This application and that rhe work will be done in accurGance with San Joaquin cOunly ordiruncts state lawn and <br /> rules and norficnaenof Itis Sen Jwqum Countf a I ceny test s <br /> nvvr,er or reaed egtnt[a'0 niers c0-111-96c0-111-96 thelo�lowtni� m tfw ptilarmence of tna wprk for which this perms is ensued I shall not <br /> Horne <br /> �t,rrloy any pdraon in such manner as to tscnn,e subject to workmen s eampen}atro�laws of Cetrinrrva Lonlractor s hiring or waeontractlnq apneture <br /> eenifies the fol1&AotV I certe'Y"I in tits pviorrnanra of Itis work for which the pairrut is tasted I"ll employ persona subtaet to workman a rornpensa <br /> tion laws or GlHornle' <br /> ,�,��_x,' r,. =a'fr�• ' _fSr�T!>!afrlGunt arwaj Calk for 89 r uN ir,lpectgm p€ote drawtnp on r sa s+do <br /> Mfr }rlM Et37 f , Srp 1 Title Dail l� <br /> ~' v <br />_! FOR DEPARTMENT USE ONLY292-f <br /> i <br /> Appkks6cin Accepted by Dille ran <br /> ! Z g <br /> Y.r._ pUI or drout Inspection by Date Final Inapection by fiats 55 <br /> $�� -� � '�aApplicant Return ill' copies to Ban Joaquin County Public Health Servicer <br /> r •� �, f Bovironnental Health Pertsit/Service• _ <br /> 445 H San Jnequin, 0 4 Boer 200e brio CA 83407 <br /> tY, � <br /> r O WE AMOJlrT DUE GASH <br /> AMDUNT REM[7TEp R[C►ryEP by DATE <br /> E ►lRklli w0 <br /> f' <br /> p rr ar1}eiRfY irli s 3 ! <br /> y 3`j lv <br />