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APPLICATION FOR PLRW I T <br /> SAN JOAQUIN COUNTY F►E78LIC HEALTI, SERVICES <br /> ENVIRON ZSTAL ILEALTH DIVISION <br /> P U BOX 2009 , STOCKTON, CA 95201 <br /> (2.09) 468-34-k7 <br /> SM <br /> (Complete in Tripl,icmre) <br /> — A�11Cat.loa 1■ [ratatry �made t0 5aa Joaqulo County ror a perta,t to oonatruv; and/or inata1,1 the vork herein anacrited Tr'_a <br /> app.lcaClon .s ride in cna'Plianco ►ith San Ju.4uln Cow.ty Ordlnanee No 549 and 1662 and Src fi.ree and hefr%-La,t.ons or San <br /> Joaquin Coun6y public Healtts 9ary ass. �,,, <br /> SSSJop Address 0� City �j;0]_ tat Size/A:re4c <br /> Owners Na C n timr� �� 4�3 <br /> 'tt� Address <br /> � t r+ � Phone <br /> Contractor Adaress a1v � +7W` r <br /> ►X1Urcense NeG`� $hone t26- � <br /> TYRE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT I:r p£1STRt.(t�/,TION C, GutAniwrin,6 <br /> Sarytce Well L1 <br /> PUMP INSTALLATION! ❑ SYSTEM REPAIR C; (; ] bl.'�1{r1/1 Well L} <br /> DISTANCE TO NEAREST SEPTIC TANK _ SEWER LINES DISPOSAL FLO PI"ROE)LINE <br /> FOUNDATION AGRICULTURE WELL .OTHER M'£LL PITS ISUAAPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> rl Indurt+u► ❑ Open Bottom a Miinleea Dre of well Excavauon Dia of Well Ca■rng <br /> U 00erastic/Private CI Gravel Pact C Tracy TYPO of Coiling Specification@ <br /> ❑ Puotre f'i Other 0 Delia Depth of G+out Seal ~' Type of Grout ' <br /> M Irrayanon _ Aporox Depth O E.starn Surtice Soot Installed by.A--joS <br /> Aepatr Work Done L] Typo of Pump H P Stere Work done _ <br /> Well Destruction ❑ Well Dtemaiar 3co11vi.a Kaceri&l A Pvyth <br /> Depth Tiller K*tertal i Dcpth <br /> _ TYPE OF SEPTIC WORA NEW INSTALLATION 17 REPAIRiA001TION L1 DESTRUCTION ler $No septiz system prrrmrrlrrl if pwil,c liv d+ in <br /> avedahla within :90 loot 1 <br /> ln:4114140n will serve Residance Comme(clat_ Other <br /> NwrnWr of hying units _ Numner of oadrooms <br /> Character of Wil to a depth of 3 feet Water table depth <br /> SEPTIC. TANK ❑ Typo,Mfq Capserty No Coenoonmonts <br /> PKG TREATMENT PLT. C1 Method of Dr t <br /> aposal <br /> J Dlstance to nearest Wetl Foundation Propeny Line <br /> ,LEACHING LINE Cl No b Lrnpth of Ines Total length/ars♦ <br /> /FILTER BED n Distance to nearest Wall Foundation Progeny Lina <br /> SEEPAGE PITS If Depth Sue Bumper <br /> 111 <br /> UMPS LI Distance to nearest Waal Founoanon Property Line <br /> _ DISPOSAL PONDS 13 1 <br /> I hereby sandy Inas I have prepared grits eppl+canon ens that Ino wpek will bo dune in acC0ro3nr:a with San )aaquin County ordinances state taws, enc <br /> +utas and raqulations of Ins San Joaquln Coun.y <br /> Momir owner or licensed agent s s,onature can,lies the followMp I cattily Inst in the Pomormance of the work lot which this perrhrt r5 issued I shell not <br /> OmptoY arty parson in such manner as to become swbiecl to wt;rirman s Componsaiio i laws of Cslrlornra CorwactGr s hiring or sub contracting srgnatuie <br /> cartd-as the 1"Ol ving 1 carttfy that in the portormence of the work for which this permit is tasusd 1 shell ■tnploV Daf was suslact to worf,man s compensa <br /> IIOA laws of California," <br /> ha applica .-. uel Cal all recurred inspemons Complete drawrnq on faver54 s,do � <br /> rgnod Title pate <br /> FO DEPARTMENT at ONLY <br /> Apphcatlon Accepted by Dela �' Are■ `" <br /> Pit of Grout Inspection by pato Ftnal Inspection by Date , <br /> Adolt+onat Comments <br /> �APPILCe.nt - Retuty LU copier tot SAX JOAQU]N COUNTY PUBLIC HEALTH SERYICES <br /> FNVIRONI EI(TAL HEALTH DIVI$10H pER1/IT/SEIVICES <br /> 444!1 H SAN JOAQUIN, P O LOX 2009, bTOCKTON. CA 0!201 <br /> FEE <br /> INFO AMOUNT DuEE� AMOUNT AEbr+''TED AS7H� ItECE+vEt) 8Y Dn rtE v/fAMIT h0 <br /> IRev ires) 1�3 <br />