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moor— <br /> APPLICATION FOR PERMIT n' <br /> BAWQAQUIN COUNTY PUBLIC HEALTH SJ*MVICSS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOC 2009, STOCKTOiN, CA 98201 �a�/ �• <br /> (209) 468-3447 <br /> (Complete in Triplicate) <br /> A"Ucatiea is hereby wAs,to Seo Josqufa County for a Permit to cagetruct and/or install the vork herafn described. This <br /> e"U44t4es is NW* in eoigifanoe with San Joaquin County Ordtaww* No. 349 said 1662 sad theluks and beMthatloss of San <br /> Jesgals eavow Public swath swrfces. <br /> JobAftwe ✓ �/ City 2 XA APF7 Lot use/Acrew A///f <br /> �t G 8 / A A'"AOCO., +� <br /> Owner'a Now Address -- San .Tok Com. Phw►e <br /> Contracfa�! G� t74i�, Address _ice P c �E� r,,=L"nse No. Phone <br /> TYPE OF WELL/ MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out or Service VOU <br /> PUMP INSTALLATION ❑ SYSTEM RVAIR ❑ OTHERR llaaitorts8 Mill ❑ <br /> OISTANQ TO NEAREST: SEPTIC TANK 7/00 r DISPOSAL FLp /s' PROP. UNE /,fid <br /> FOUfSOATON ZAE.L— AGRICULTURE WELL;''/I?" OTHER WELLM6 f. PITS/SUMPS]190 / <br /> INTI JOW USE TYPE 00 WELL. PROOLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n lnduaaiet 0 open Hann D Manteca Dis. of WON Excavation Dia. of WM Cod" <br /> U OonteeftiPrivate ❑ Gravel Pads D Tracy Type of Caine $paafioerone ~""' <br /> C1 Pubk �/3�DOW JbW" a 0" Depth of tirnut Seal _ _ trtQ.,.. Typo a irsu '"i'� <br /> a knpd n App os. Death Esewn SuAice Serf Unstaad by <br /> ROW /•,g% <br /> RW Vlfmk Oona E3 Typo d ow" N "1 H.P. AIA Sure Work <br /> II/ G we Dhinstat Sea "4 wtwPlal —1NPuI . -s Y0 4 0 ' <br /> — MW 956 Auer IbWial & Depth 40 •• <br /> TYPI $60M WOAK: NEW INSTALLATION 13 REPAIRIADOIT1001Q DESTRUCTION 0 INo wp*syswm&moulted if public sewer is <br /> evadable avenin 200 fest.) <br /> Instabdon w1E um. Residence— Comnwdo— OIMr <br /> Min" of k"units: Number of bedrooms <br /> Chanew at.sob to a depth of 2 feet: Wear table depth <br /> SEPTIC TANK a Typolmto Cap"" No.Conparbnana <br /> PKIL TMATMIl NT PLT.O Method of OMpoeM <br /> Oietanoa to nowet: Well Foundation Property Line <br /> U IACHM LINE ❑ No,a tenpin a ones Total length/ <br /> FILTHf SED ❑ 01stance to ne~ Was Foundation Propew"Line <br /> SEEPAGE PIT$ 1 I Depth Nugtibar <br /> SUMPS Ll Distance to nomw.. VWII Foundation Propany Lina <br /> 1111401►9&Vv dwa I hava Onaead NNs appkstion etd that the work wig be done in accordance with San Joaquin county ordinances,auto leas6 and <br /> twin and NVAMiena a ane San Joaquin Carew► <br /> Home osmar ori Ileegaad 80WWG ayrneEurs car%Rse the following: "I certify that in the performance of the work for whioh this permit h issued, I shall not <br /> �t>nfr parrot iR tsgdg ntangge►as ce bsragw eubjsat la workman's oompertsalion Jews of Cebfo*rtia."Contrsetore hiring ar tub.eoneractina si0r+atura <br /> tion bas M 4111M►that to eft Palorntanes of the work for which thio pare h hwed.1 ahaE amplay pareona subject to workman's g ortnpargaa- <br /> The appsiaant trust sM far an rsgtiired Complete drawing an mvwn We. <br /> sad <br /> quTia• n7 Dat.: ��3 <br /> FOR DEPARTMENT USE ONLY ST 27.00 <br /> ApvNe~Aaaepad by pea 'Zrl / vi # <br /> Pk or Omit Inspwaon by Dote •!• fRnsl Insgeallon by � <br /> Ampme.WLIe rj-)C; <br /> Agplicsa! • Ne%we all copies tog so JOMOUIS PUBLIC UiALTX $3XVIC11:0 <br /> 8XVISONOWAL NZALTa DIVIBIOtf PZINIT/$MICAS <br /> "I M SAtI JOAQUIN, p O a" 2009, $TOM-=, CA "Sol <br /> gal E0 <br /> AMOUNT DUE AL42UNT InEANTTEO CK <br /> 11 H RECEtVEOCASar oArtt ►Ef1a1f/T- <br />