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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONKENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 488-3447 <br /> pE811IT BZPIBBS 1 YAM IF DATE ISSUED <br /> (Complete in Triplicate) H <br /> An Ilesties is horety naN,to Sea Joaquin County tar a permit to construct and/or install the wort bersin described. This <br /> gvilesusto is Erle la "Nollik"s With But Jostluin County Ordinance No. Sao and 1862 and the Rules and Regulations of Son <br /> Jospin Maytag Hillis Halm services. t <br /> Job Additive � Q vela City 1/L Kit urs/Ac,vap <br /> oil wo"Mie l/.t_G / -�2Z Address �>!7�`W ( s t �U Ph" <br /> -3 !o <br /> Cannactar ei _Address License No.463f 4 Z Phone "' / <br /> ryn 00711LIPLIMP, NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION C3Out of Service Well <br /> PUMP INSTALLATION P- SYSTEM REPAIR CA---- OTHER O Monitoring Well El ' <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROF. LINE <br /> FOUNDATION AGRICULTURE WEII OTHER WEII PIT$/SUMPS _ <br /> INTENDED USE TYPE OF WEII PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O tMuS"rial O Open[oaan O ManwoO Out. of Wes Eacawnon Dim.of Woo CA&V <br /> [1 OmmaKe/Pnwa 0 Gravel Pack O Tracy Type of co" Spectfiunonm 1 <br /> Il Other O Doha Depth of Grout Seat Type of Grout <br /> — <br /> a Irogatlen Appro.• Depth O[sown Surlier Seat Inatased by p <br /> 0101111111f Wort Dose V- Type of Am* H.P. C-- Suis Work Dons <br /> Woo Destruction O WON Die low Steeling Material A Depth <br /> Depth Rller material A Depth <br /> TYPE SEPTIC WORK: NEW INSTALLATION M REPAIR/ADDITION 0 OESTRUCT*N Ci 1No sepne system ps"r~it ptobkc»war Y <br /> g available vmhin 200 too.) <br /> Imetelolion wN eBay. A sidartc _ Convtwrcial_ Oihw <br /> Number of"vtHw: lawrtbp of bodrooi r <br /> Clwscter of so[to a depth of 2 hat: Wotan table depth V <br /> SEPTIC TANK O Toot" Capacity No,Compartmmnts <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> Owwwo to Iow Woo Foundation Pronerty Line <br /> LEACHING LINE C1 No.i Langth of krw Total length/size <br /> FILTER BED Q Distance to rwreat: Was Foundation Property line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS LI Ditanco to rteasot: Was Foundation Property Lin <br /> DISPOSAL PONDS O <br /> I hanby certify that I levo prepared this eppkcahon and that to work will be don in accoraance with San Jo"uin county ordinances,stew laws,and <br /> rule"and regulations M the San Joaouin Count' <br /> Hona owner a 11 M0 d agent's at[nStvw oMtifitl the fosowK+g: "I comity that in the performance of the work fa which this permit H iasued,I"it not <br /> employ arse PMwn In Such new~as 10 become subject to worlinu n's twmpensatwn W"of Caiaorrw -Contractors having or sub-contraeting signature <br /> k conOw the febwinp:"I ew0y that in We Wonwta of the work for which this forme is issued.l"►lel orrvoy persons wbloct to workms is convert". !! <br /> tion laws of Calfontle." <br /> The appftww rn mor so. pRetiorte. complete dewing On nverM tide. '. <br /> J <br /> Signed Y _ v_ Title.��4, 4��- Data: <br /> D[�Ft ��v <br /> S <br /> AppkstNW Aseeptad by c e� Date Area <br /> ►k or Omn Irtepeetion by Dan Finer Inspection Dat✓ 1 <br /> Addi Comrwrts: _ <br /> Aypll�snt - Returs all copies toe SAN JOAQUIN COUNTY PUBLIC NBALTN BIRVICIB <br /> ONVIROMMINTAL NNALTN DIV18ION PUNIT/BtRVIC1J <br /> 116 N BAN JOAQUIN, P 0 BOX 1000, STUCXTON, CA 96401 <br /> rE! CK <br /> AMOUNT DUE Amovkr ItEM11TED ItlCltvED av OAt! FIRM11 p0. <br /> INFO J) A M <br /> fa 13241afv v.5� r OV V—/—Q <br />