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APPLICATION POR PERMIT <br /> SAN JOA0114 CouRTY PtMLIC IMALTH SERVICES 1J <br /> I ENVIROMMENTAL HEALTH DIVISION <br /> P O SOX 20091 STOCKTONO CA 95201 <br /> (209) 499--3447 <br /> I <br /> (Complete in Triplicate) Imo`--X30--oy <br /> Applieltl6h is hoto%y Inde td god JalgUift eduhty tot• 8 <br /> i •pylicAtioef <br /> is Inde !N tearpiiance with !illi Jeaquin County Ordinlneerialt t6 nNoruSLgltror <br /> ondo1862a�d theaquiee herelin described. TanThis <br /> + JoeQuiA COUrlty ilhtb i Q u lth Ieervlt:el. '. } f r <br /> Job AddrHiS r d� was n t �h <br /> CRYS-'ro'c-10" Let Pisa/Acrekga 1 •5 A- <br /> Owner's Norrie ram .S t a Addrel! ZZ461 W. 1/4IASHi�1�pN Phone( oq 1 07A6 <br /> Z01'7 OWUOLb tNd,g trtwq� t,.lt <br /> COntraettlr� b¢fu.l+.t�_Address s`" a y <br /> License No-iQUA t/.CC`Phont StvG>�o 4!¢� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C7 DESTRUCTION Cl out or Tarvlee well Cl <br /> MUMN INAtALL11tIe7N'f 1Y9TEM 91EPA1R t7 NantlsalrinA 11!17: <br /> DISTANCE TO WOW: SEPTIC TANK _ OTF1aA <br /> SEWEA LiNE9r re3 DISPOSAL FLO. PROP. LiNE <br /> INTENDED USE TYPE OF WELL Pp09LE GAICULTURE.WELL 1 OTHER WE PITS UMP • <br /> W B <br /> M AREA CONSTMUCTION SPECIFICATIONS <br /> rl Ind,:trill 0 Open 80flont b M/niks <br /> bit. of Weft Excavation a bib. of Well Clstnb i <br /> U Domestielt*rlvAle V11 Grovel Peck a Tracy type of Casing b fyYG <br /> M Prrbllc Spacificbtionl <br /> I:1 other `K Detto bapth of Groul Soli Typo of Grout <br /> r� trriOeNon Adptbt, f)epih ❑ Ebltem Surfic/ Saul thslailed by <br /> ROOM( Work Oon1 tj type at Pump <br /> Welt De1trlletl6n <br /> d Wbfl blernefer 86llitia Ifatariill f)Epth Stiff Work Ddne <br /> Depth tiller ktOW a Da}Sth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ AEPA1Fl/ADp1TtON C:i DESTRUCTION Ci (No lepric lytlemrrbli ermilled it <br /> aVAilibla Within 200 feel.1 p c sewer is <br /> 11401101180001Wife!arra: 1{ellderlc+l== CbfnrltArefAl� Other` • _ <br /> Numbet of llvino pail!: Number of bedroomi ✓ <br /> Character 61 011 Id I depth of I feel: <br /> StEPVC TANK 0 ty0limto Weser tbbl* depth <br /> PKG. TREAIME 4t 00.C1 C►pbtlly No. COmpertnientl p <br /> DibfInce !d hebrelf: WellMethod of Oflposal <br /> Foundeflort p100AHy Line 9 <br /> LEACHING LINE Cl No. A Length at Brio! <br /> FILM 9Ebtots!! fa g <br /> n Dlaton <br /> ce f6 nebteif: Well ,#oundltion <br /> SEEPAGE PITS I 1 Depth Sire y <br /> SUMPS Numti / <br /> LI DislAnce In neerelt: Well EbundlNon S/1NP I <br /> DISPOSAL PONDS El --t,��t �', s <br /> I hereby certify that I hovWISION <br /> e prepired thil Ipplicitlon Ind that the work will bb done In Acc nco wit San Joaquin c6unty ordinbncel, list* laws, and <br /> rules And reaulbtione at the Stn J61#UIR e6dhty <br /> 40m;owner Or ilelriied!dont'l iigneture certiflol the Ifollowing: "i certify 1W In the peri'ormanco of the work for which this permit Is illued, i thele not <br /> employ Any peHtSri Ih lutlh rttlhner As ii batBFite u,bietf 16 workmin'1 coml5AriAblian lewl of California." Contrictof't hiring or sub-contracting signature <br /> eertffles the follawlno: "I Willy thlt In the pbriOrt"Ancili bf the work lot which this permit It issued, I shall employ persona subject to workman'*compansa. <br /> lion low#of C/ilfotnll.•• <br /> The epplicbnt mu Ili f f All r It/d 111`40600ne. COrnplefe drswfnp on reverse aide. <br /> Signed TIMI: Dole: .5 7(f R Z <br /> t>rr+ asci <br /> Fo� DEPARtMENt USE ONLY <br /> APPllcatlon Aeeepled by <br /> -7 1 V_ 7 r If� 7 QS 7 r7T Date Arab v <br /> Pit Of Grout Inlp*etlon b '��P� �3 <br /> ate 2—Final Inspection by Data <br /> Addldonsf Comtnent/. <br /> Applicant - Return lei Copia* tot SAN JOAQUIN COUNTY PUBLIC i19ALTH ARRV1C$s <br /> ENVIRONMENTAL HEALTH DIVI$10N PERYET/89AVICES <br /> 948 N SAN JOAQUIN, P O 90]1 2008, STOCRTON, CA 98201 <br /> fNFO <br /> FEE AMOUNT OLIE' AMOUNT nEMirrro K <br /> CASH RECEivro BY DATE <br /> y �j #7 PEFIMIT NO. <br /> IN r7,14 r1t[V.i ih 61 �1L a��r `�[ C �� �� <br />