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0 APPLICATION <br /> F <br /> SAN JoAQUiN COUNTY pUELIG HEALTH SERVICES <br /> SN'�I$ON 1TA7; HEALTS 1AVISION <br /> 445 N STT jOAQVf 14 i P $ONZ (269)468-3420 <br /> c <br /> P O BO$ 2003j STOC$TONo CA 05201 <br /> JIM, 11 EXPs jA. .. SIIm <br /> (C0mP1Ltd is Txiplicltd) <br /> Application ie hereby laid* tri Sdto "AULA Coutny fat• A 1)6fiit t6 6oahtruet Aed/br itistAll the work tier*ib described. Thia <br /> igplieition ie teed* !3f coetpliiiiice Vith gad Jot0in Cotanty OrdiMfi4t No. 54g Aird i6Q Aad the Flealed and 1taguUtiaan of S&O <br /> :I'oe4uin County Publid Httlth BervieeA; <br /> Jab Addrasit 3 0 4 9 W. Hwy 12 <br /> City Lodi Lot Sia*/Acreage <br /> O*natrt Name Sonny Patel Addrsis <br /> phone <br /> Oil E ui San Andrea (209} <br /> Andreas, CA <br /> Ca+attaetar Ptnent Serv,rtddrelf 750 IndustriaY LICOrtti No.3t Phone )754-1808 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP MtALLATioN O SATEM AEOAIR ❑ OTHEAXXaitorin4 well 0 <br /> DISTANCE TO NOT:OT: SEPTIC TAMC Srrll�lER LINE DiSPO§AL PLO. PROp� I a Boxing <br /> FOUNDATION ... AGOICULTUAlt WELL - -- OTHER WELL - - PITS/SUMPS <br /> INTtNOEb USE TYPE OP WELL 010109LIM AAPA CONttALICTION SPECiPICATIONS <br /> n Industrial ❑ 0046 aaitom ❑ Mbnlict Dill, df Well Ei civatiori Dia. of Well Citing <br /> In Oomestid/Prlvala ❑ Gravtl Peek ❑ TracY Type of Cayinvg 5peeirleationy <br /> I'1 Public R1 Other h Dilts 060th of Grout geal Type of Grout <br /> I I Irrigation Aoprdit, baplh 1 I tAitirrS SurtsCt Saul lnstalled by <br /> Aegair Worts Done L] Typo of Pump H.P. Stitt Work Done , <br /> Well Destruction ❑ W411 biamaier "Aline witAftAl A Depth Cement/Bentoa i t-�- 4 <br /> Depth Pi1l4r hittrN <br /> iti A berth _/A -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 sePAIR/ADDITION I I DESTRUCTION I I INo septic system'permilled it public sewer is <br /> available within 200 le4t.1 <br /> Installation will #4rva: Re3idehce— Conaml4rtiel„____ Other <br /> Number of living units: Number of bedrooms 7 i <br /> Chareetsr of can to a depth of 3 ftttt Witer tablt depth <br /> SEPTIC TANK. ❑ Type/Mtp Capacity No. ComjMrtmdnts a <br /> PKG. TREATMENT 01-T.❑ Method of Oicpos 1 , <br /> Otstined to natrkt: Wall Foundbtion Property Lina <br /> LEACHING LINE ❑ No. & Length of finds Total length/site <br /> FILTER BED ❑ Diitinca to nasrett: Well Fdundetion Property Lind <br /> SEEPAGE ptTS I 1 Depth Slta Number <br /> SUMPS Cl Distance to riiaPM: Will Poulidiliah Property L1r4 <br /> } <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared thin ipplieatiorl and that the work wilt Iia done in eccordaned with Sin Joaquin county ordinances, State laws, and r <br /> rules and regulalioriA of the Stn Joaquin Cautitk <br /> Home owratr or litinsid sgitiYi iipriiwid cartifiea thi followmd, "I cbrt6 that]n the performanca of thl work for which thit permit is i#sued, I,hell not <br /> #mPIoY in*ptribh in such ffi6hk&Ai 0 b6dbine eubitet to workmen ti coriipmMtion taws of Cilitornia."CoAtrictoes hiring or sub•contricting tignatwe <br /> certiflia the(otlovlrrnq•"I eiirtify that in the pe d►tHahce of the work for which thin permit it Itsued,10411 employ pariony subject to workman's compenia- <br /> tionti Cyt : <br /> The acAn t 11 f. in dafti. Corholtta driwind cri vtrsa aide. <br /> 5lgnad - Title: .._. Data: 401ZO G-- <br /> i <br /> POR b��Af��MENt USS ONLYAppticyticti Aeraptid.by �. _ ..,.. ,. ,.. Data � Q%! Q�- <br /> Ares <br /> Pk or drout Inepilictlon by fG•�vE Date q <br /> Fihil Incpaotiori by Data l� <br /> AddRidnyf Comrtienti: f <br /> Applickht - Return All corie3 to: $Mai -fdaQuin Ccisntk Ptiblid Rdilth serviceA <br /> Invi:rodm6atil geiilth #erCnit/Sdrvicd6 r <br /> 446 N stn .Ioiquie, p O go* 2000; St*h, CA 0201 <br /> 1FEE AMOUNT bail: AMOUNT Rimirreb -ASH <br /> PIecelveb,9Y DATE pEgt,t17 NO <br />