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APPLICATION FOR PE"IT JOARUIN COUNTY PUBLIC HEALTH SSRVICNSPOP <br /> SAN ENVIRONMENTAL HEALTH DIVISION„. PHONE (209)�46B�3`i< <br /> 1801 K. <br /> HALRr..ON AVE. r VOP, C� 5207 <br /> Fly <br /> P O BOR 2009, STOC <br /> i RES YEAR R B �-� <br /> m lute i¢ Triplicate) This <br /> (CO p tions or San <br /> uin County for a permit to construct and/or <br /> a.drB62asndlttheBulea en deFlegulaeTibed. <br /> • hereby made Ona Jos4 county ordinance Ho. 549 <br /> Apylieasion 1 licence with San Joaquin <br /> applic►tioa IN made in comp Tr Lot Size/AcraaBe <br /> Joaquin County Public 11thHealth Servree. City <br /> 950 11th Street (805) 644-6784 <br /> .lob Address P.O, 13oX 1601 s <br /> Oxnard, CA 9303ahone <br /> petroleum Address 916 fi3�721 <br /> ng9ert 5549'19 �� Phane� <br /> owner's Name License fIo• <br /> Address 23 <br /> DESTRUCTION Cl Out MaRitoring Well L9 <br /> ContractorWELL REPLAC OTHER 0 <br /> NEW STEM REPAIR D PROP.LINE r <br /> TYPE OF WELLIPUMP: WELL 0 SYDISPOSAL FLO..,�.� pITSISUMPS <br /> QUMP iNSTALi A31ON SEWER LINES OTHER WELL ^ <br /> DISTANCE TO NEAREST, SEPTIC TANK 2” S1 <br /> FOUNDATION �-r AGRICULTURE WELL ~�PECtFICATIONS <br /> TYPE OF WELL PROBL REp CONBON S <br /> Dia,of Well Casing 401?VC <br /> INTENDED USE -r^��' C]Manteca Ole.o!Weli EMco Ztio gpecilications <br /> � E p Open Bottom Type of Cesing far Type of Grout <br /> n industrial Tracy Lj f h <br /> •i T 1 Domestic:Private ❑Gravel Peck 17 papa Depth of Grout Seat <br /> I:1 Othor surface Saul Installed by <br /> f l Public State Work Done <br /> _�Approa.Depth I Y EasternH.P. r•� - <br /> I I Irrigation Type of Pump '^ eenlittg tMaterial i Depth <br /> Repair Work Done U +�`^ <br /> Well Diameter Filler tfeterial� Depth tic system permitted it <br /> public sewer is <br /> Well Destruction Depth lgr ova+Sable wilhln 7.00 Ill <br /> NEW INSTALLATION,1 REI ROADD17lON i 1 DESTRUCTION I l SNo sap `) <br /> TYPE OF SEPTIC WORK: Other <br /> Ccmmbreiat 1 rte^ I <br /> Residence r llation twill serve: Number al bedrooms Water table depth <br /> Insta <br /> �_ No.Compartments <br /> Nu bar Of <br /> livin�trts� ael� f <br /> th o �apaEity�� Method of Disposal <br /> Character of soil to a d0 TypalMlp <br /> SEPTIC TANK. Property L'+nVA' NT <br /> PKG.TLT.TREATMENT PWill�-Four Atian 1 <br /> Distance to nearest: <br /> TotallongthlSrty �t � � '993 <br /> 01 linea Property Lin J, <br /> LEACHING LINE L1 No.d LCng Well��- Foundation r-^ <br /> FILTER BED Cl t once to nearest: SAN 10A L"N CpUVECFS <br /> Number <br /> ll <br /> size y- �CTi`EALTN DNV1 10N <br /> SEEPAG I I Depth <br /> �—Wall_1- Foundation�-�Pw� <br /> SUMS LI Distance to nearost: rdinenees,state laws'and <br /> i p I shall not <br /> _ LOISPOSAL PONDS <br /> i a prepared this apPlicetlon and that the work will be done in scwrdancc with San,laaquin county a signature <br /> 1 hereby sorrily that l fill+, rtormance of the work for which this Permit b contracting <br /> a tato <br /> rules and regulations of the San Joaquin t Darty 9:• arsons subject to workmads camp <br /> t tai's signature canifies the tollowin 1 cortily that in the i>a I shall employ P <br /> Nome owner or licensed cep p rmll is <br /> issued, <br /> em IOY any Parson In wah manner as to t in the perfoemance ol�ha wo kaloswh eh this Pan laws o!California.' Contractor's x n9 <br /> i I <br /> certify the Gt� <br /> ; eanllieslhafollawinp:' _ r-• -- 7 <br /> tion laws of Calilomla." plate dial or,reverse side. <br /> (or-el1_requrr_sd inn!'C° <br /> �`--—�-Gcent music - ---{- Fill <br /> The app Title: <br /> Signed FOR DEPARTMENT USE ONLY I� <br /> Date <br /> v Arae <br /> Aceta r - <br /> APPlieallon Aeeeptad by Final inspection by <br /> Date r� <br /> Pit or Grout Impaction by �^O <br /> Additional Comments: p+zbI Health (7j <br /> Applicant- Heturto all copies to: 6nn Jon4uin County jjj <br /> S n Joan. n Couonmental Health Peinitsto kton6 CA' 95201 <br /> 1601.E. Hazelton Avc.. P 0 Box <br /> 2009, PEAMIT'NO.. <br /> - - - GATE <br /> CK RECEIVED fly <br /> AMOUNT REMII"IED CASA <br /> - . FEE AMOUNT DUE <br /> �� <br /> -' INFO pi'O� 3TO [� <br /> 'I • EH Si.le tREV. <br />