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P.4 ►, x - .:'+JU! '9U 13;59 �,LTOh1 l ... APPLICA'TION FOR PERMIT SAN arar�aUI1R g3�,NTAL H.�ALTY PUBLIC H DIVISION SERVICES X420 { gjVIR PHONE (209)468 1601 S. SAZBL�'ON AVE. , =: p 0 BOA 2009, STOCgTQ2d , GA 95201 � g Y it gR I (Complete in Triplicate) r /,pyl1catioa is hereby meat"ta "+ JeyeQuin County far a yarmlo to cOneLrucC rsgd/ar Install the uorkles herabd in Re ulavYjbed• Tan 1 application is reads is ca�Biiance with Snit Jpaquia County brdinanee No. SL9 and 1862 aar3 the Rules e.!nd Aegulatioaa oI 5an Joaquin Cauaty Public Htslth 9ervnices. ��r7 � •.�� " City Lot Site/Acreage Job Addfass �¢ .21 Q,lQB/1N C�_ Phone 3`71'26 rL� � �P• Address L Darter"a I•tarzfe i J .,. �J_��,�°AA- ... Address 3 )i3k uc - No.;a—Phon 63$-727 TYPE t"!:Li:6uMf;: I�EW wEt s WELL REPirACEMENT E] DESTRUCTION O Out 0! Service V61-1 C1 : .SYSTEM REPAIR © r ,i- •. OTHER.© Yloni W r1 e t PUMP WSTA!-010N 0 n - � lc DISTANCE TO ,L'EAREST; SEPTIC TANK �---r SEWER LIVES � DISPOSAL FLD,— PROP- LINE FOUNDATION AGRICULTURE WELL OTHER WELL— P11SISUMPS INTENDED USE _TYPI< OF WELL PFOB EM AREA CONSTAUCTiON SPEC191CATIONS , �R�tf Industrial 0 Open Sottom ❑ manteea Dia, of Well Excavat o,,1 f d Dia. of Well Casing-- j Trac Type of Casing Specdicafwrta JA Dwndslie/Private Gravel Pack Y t Type of trout. 89A Z:CfadrfiY.0 I'I Public I;l Other Cl Delta t]epth of(rout .. Scat I br" tion Approx- Depth t I Eastern SurfAca Seal installed by -WE 4 T Repair Work Gane D Typs of Pump wp. _ State Work bane Sealing tlatesrial i Depth l Wall Damnation Q Well Oiarneter r_� l Pillar Materialrlal i lhaspt Depth ts TYPE ds SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADOITION 11 ,DESTFIUCTION I I iNo septic sYstatn psrrn0ed it public sawet is available within 200 feet.) Instigation wad serve: Residence Cofftmer6e1— Other - ' a Number of twee units: Number of bedrooms\ �` Chwbctof of sod to i depth of 2 toot: -. - Water table depth` SEPTIC TANK 0 TYpatirtf¢ Capacity__,.__--�— No. Compertm+nts PKG. TREATMENT PLT. 0 � Mathod of Oisfwsal t7,4granea to nearest. Well Foundation Proparh/ Lina LEACHING LINE 0 No. b Length of Eirbs Total Iangth/area + FtLTEft $ED C1 Distance to nearest: Wel! Foundation Property Lina SfETA"PITS 11 0001h - -- - --Size 1Vurr r sumps Ll Distance to nearest: Wad— Foundation Property Line,_ DISPOSAL PONDS a t hereby certify that t have prepared this application and that the work will be done in aCCordanoe with San Joaquin COVAIY O(dinances, state lsvra,and 10 ruler)and rol;tulatrorrs of the Sri-) Joaquin County Honor*vVner or licensed seam's signature rectifies the following: "I certify that in the performance of the wprk for which th"+a permit 6, Wood. 10%14 not rtsnpspyr any parson in such manner as to become avbiect to workman's compansation laws of California."Contractors hiring Or sub•contracling signature c*etifiss tho following."I certify that in the performance of the work far which this Permit is issued.I shall/rnptoY parsons subjAt to workman's comiw a- tion taws of CAliioenU." The apoicam rnLmt call for M repuited ns, Complete drawing an reverse side, a s;p _ ri' '^.�--'T Tithe: �Ae0zfd--' r` D4PCe rSt Dtt�, 763 a TAE I bi+4 K. G,,,r,t FOR DEPARTMENT USE ONLY Appkcatlon lscceptad by Date Area A Pt! tr Ijtion [ _. E]ate(�/ L'ol-D— Final Inspection Add tkp%bl Cor ry tants: A pl csiA4 - Retorts all copies tot Baa JoaQu.itt County Public Health , Services, MaLArommota.2 Sealth Po"It/services 1601 A. 8asoltaa Ave., P 0 Box 2009, Stockton, CA 95201 FEEINFO A1Ytt7lrflT otJE AhAQUN:ME11tl?TEl7 GASH RECEIVED Ily DATE PEAWT-#ip. £hI tai±Irtrtlr.1 0 R su -_ �(j . 03 L/ .