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i <br /> J $ <br /> i <br /> .. � .�. ���� L' YY1nvi�o�:�► ;amu �... <br /> 0 <br /> 'WPLICATION FOR IlE"IT <br /> SA.*t JOAQUIN COUNTY PUBLIC RRALTH SERVICES <br /> t4V1RONUENTA.L HEALTH DIVISION <br /> 1602 E. RA'LEsLTON AVE. , PHONE (209)468-3420 <br /> P U BOX 200U, STOCKIYJN, CA 95201 <br /> �•- .1r1:.rMIT_Wit g ISSUisIZ <br /> (CoMplate in 'triplicate) <br /> [{ Application f• hereby made.W r• h Ja.quir. Caanty !nr ■ permit to construct and/orinet&ll the work horeln described. Tttt► <br /> ap <br /> plic■tIOD ae wade in ccowl'ance with San Joaquin CO%-ntY Ordinance Ilu. 51.9 wnd 1662 and the Rule■ and Aeaulattons Ot' San <br /> r-r Joaquin County Public Health Service!. <br /> E C��LIC1l l �'tv�1 1 of 5s ce/A.-rcelfe .�� <br /> Jub A0:]rsst< Lr, L1/ <br /> d ^t Ir�� i hneresl �.�i1���----� - Fhone y`•r <br /> 0vvrt►.0's laame r li 1ie_f -_ <br /> P^Dns <br /> fi. <br /> 'TYPE OF NELLIPUMP: NEN WELL _Cf7 4�'Eti.REaL✓:CEf,tEt.T f' DESTRUCTION ("r a'L Of;;-'-1c* <br /> Well � r <br /> PUMP INSTALLATION A SYSTEM REPAIR.El CTHER (i <br /> PROP, LME <br /> DISTANCE TO NEAREST: SEPTIC TANK SEVAA LINES ____ DISPOSAL F16.__ PITS/SU%lPS <br /> _ FOUNDATION AGRICULTURE%%'ELL OTHER WELL <br /> F3. INTENDED USETYPE OF WELL PR(-IRLFM ARTA CONSTRUCTION SPECIFICATIONS // <br /> _ <br /> Cl Indusle 0 Open Bottom n Monaca D.a of LValf E.cavanon D .of Well Caa+np <br /> omeal+clP•ivate C1 Graved Pact l.7 Tracy Iype of Caa:ng"_.._- . ----- <br /> tic <br /> -- <br /> .'I Public li other [3 Delta Depth cal Grout Seri ter- Type of woos. <br /> 3 — <br /> `. Irrrpat.on � plNos. Depth !f Ea/tern $urSaCe Se+V tort cried try <br /> ..,; .� / !LP, Z Stale Wort Done'-'pd <br /> �. //��� <br /> ,r. Repair Work Done J Type al Pump j� ;.J_ - " <br /> /� sealing Material 1 1%19t1 i <br /> +T Well Ontruction ❑ Wall Dru++tI r _4 <br /> - Depth�f Y11ler <br /> - <br /> t <br /> TYPE OF SEPTIC WORK: NLW INSTALLATION I I REPAIR/A.'?UITIUN 1 t DLS:I;UCTION I I INo septic nininSvslem feet.) d grW.c Mew/r rf }. <br /> aYaaotHe within i00 fee 1.) <br /> Insteaation will serve: Residence COmrMrcul,„T Olher _ <br /> Number Of t»droomt <br /> +, <br /> Number Of 7ivrng urwts:�, , <br /> Water table depth <br /> CMratter of so+to a depth of 3 las: <br /> SEPTIC TANK 0 TypelMfg CaPacwY � 'Na.Companrrwrtls <br /> +';?:i',. AMtlx:d of Disposal <br /> PKG,TREATMENT PLT.t:7 t <br /> ° r'•"... Distance to nearest. Y:etd -- Fo-xrdepon Peopeny line <br /> LEACHING LINE 0 No.&Length of hoes �_—..�� Taut bnytnlsar� <br /> FILTER BED i:l Druance to neawu: Ws1! -^ yFt.indatron P1OPer11y Line <br /> SEEPAGE PITS ;I peplh _ _ Sue _ -_. - __— Number <br /> �_.. <br /> �'"r �'-;,:t"•' t SUMPS LI Distance to neeresl: Yell —_ Fourwur.On Property Line _ <br /> DISPOSAL PONDS CT <br /> •' '`'.1''1 !horaD/Lertdy that I hove Prepared IMS epo"t oo and 14W 10.0 wu..'h.tl W done M accordance with San JOagrwn county 016"LCOS, clefs errs, Tort <br /> rulef find raguiatrom of the San Joaquin County <br /> Hortr GvvrMf p l.canssd spent signature certif�al 1M IOItOA&ng."i c4r0Y that to 1M perrrvmance OI tM wwa for wroth that parml K Weed,I shad not <br /> MRploy any Portion in such Milia ear as to become aubreCI 10 wOr.m4111`1 Ii CtM+PenLl�orl Lb,"of Celrft>rna"COntraCtpr'r Mor`j Or WGCOnIraC t+nQ irgnatwe♦ <br /> _ certA+ea Toa fofbwrrty:"I r�rrrfy that in the Performance of the Ac,", <br /> wl+rch Tors perr.vt:ti rsauad,f stool arnWOY persons sublets to wgfntan's compansa 4` <br /> tion la"al Celitanle" <br /> y'•+.:�'. The 8ppWAfll e0ured rstpeClNxu. Co'nptetr.'•evwng on��r.rrs�rId* <br /> . <br /> T'b:_.1 1t .W1_Ci� Date' <br /> F07 DEPARTMENT USE ONLY !� R <br /> •,r .7C ...e'1T/ Date Iq - AruApplrtapenActea[ed oy � -sit -'�---.`-..'- / <br /> • r F,ner'nepr,Ctyn by f r�.:L'If Date <br /> Ph or Grout Intp.c'rrn M - <br /> r, Additional Co nm.nu: <br /> r:•rt:;.�, /t Applicant - Rar'arn al.l codas to., San Joaquin County Pub11c Health <br /> Services, firviroruaer.tal Reelth E'eriillServl Cee <br /> 1601 E. Rate]:t.a Are..-P 0 boa 2009. F.trxatco, CA :`5:01 <br /> gfC[ <br /> afE aOAOL-ct DUE AMOUNT IItMiTtID -C�„�`{I• ryEA allrtAMll►.? <br /> aaTf <br /> •�'` � IN177a[naV ,.,, t,.�S'.� L"ft�.a1 �` Mid' l• L•`Ii t•�L.' <br /> fU •[N tI� �• -� <br /> l <br />