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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC REALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOR 2009, STOC%TON,- CA 95201 (209) 468-3447 _ P*tFt_IT Ex➢IR&S 1 LEAR PROM DATE ISay�f1Q (Complete in Triplicate) Application to hereby sada to San JwCulo County for a perdlt to Construct and/or install the York beret. deferlbed. This - application Is sade in Ceaplbnc. with San Joaquin County Ordinance No. 51,9 and 1862 " the Rules add lk* tIAtiona Of San Jdaqulo County Public Health "e�mlc:a. city2 Let Site/ACrome_ Joh Address CITY Pnen. Cd�17 DWN�a No" /nfjyt� n 07a Cot at la v'Pte// l Addren Lrcenfe No. Phone ' TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION L1 Out of 8.rvlee Yell Nonitorina Yell El PUMP INSTALLATION C SYSTEM REPAIR a OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE FOUNDATION _ AGRICULTURE WELL _ OTHER WELL PITS/SUMPS &' INTENDED USE OUTYPE OF WELL PRLEM AREA CONSTRUCTION SPECIFICATIONS r; Do.01 WEII CKlrtp - �. ❑ Con nnic 0 Open Bottom 0 Tracy Type Dio of WsII E.uvNen Specifications r j - C DomenklPrivan O Gravel Pack ❑Tracy Type of C foul Type of Grwt - M Pnolic I7 Other O tints Depth of Glom Seat l U brNlerirm — APP, Depth 0 East Surlier SWI Installed by U H'P' Smm Work Oona ReOsir Work Done Typo of Puha 9ealina lesterlal a Dept:: ' WEN D.nu n+ctidn 0 Well Dm.ur 1111.r Kaurlal i DePth ` -L Depth V 1 s r n TYPE Oa.SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION OES TR UCTION U (No able yN. fm permuted it p\rbNc ewer Is WaibbM Within 700 Intl r F k T Insmpatian wfa erne Rninnc._ ComrNrelal other W r I Nu, iar of b.Orwm _y �� r.,zu Number el Nvinp toad.p Water table dopier y r ^" LNrMer of KN to a depth of]InT: r x r r SEPTIC TANK -❑ Type/Mlp D.peCiIY No.CompennrnlE l/J PKG.TREATMENT PLT.[7 ♦ Methodof Disposal Distance to nmeft: Well 4120— Foundation Property'Line + c? ,`•Y# "-7k, IEACNING LINE �.LI NO.S Length of lines 14, — /^TjgmI length/fin ti xF FILTER SED- 0 Distance I0 neeruC Wall Foundation ..-a� PmnnY Line 5; SEEPAGE PITS 'I I Depth - Sia._ Numnr r` SUMPS t -:1 ()latent 10 nnrefe Wen etien Fothd _ Property UN DISPOSAL PONDS - O 'an+ 4 T�.4.ti I Nnby<en:M TNI I Nw prepared this apWiution and roar the worn well be done in acro Banca with San Joaquin county mdmanpf hale lawn:EIW T -C' with "k.and m2w.lions of the San Joeouin County HOmE Owy1Y Or licensed age Ngnetare Ceniliea IIN IollOwrrp ,certify that in ms Leda a N of the work for which IM9 permt It bsued 1 aMN n01 �F' J k ^u+ i empdy any moor,Yl N'th nMn",W N b.come subjeCl TO wOM1marl t COTpaNalion 4wf OI GLlornie."COnVaC10Yd hiring Or WDCOnI Kiang 4gNINe - Y C.rti1Me 1M lollewmp 'I peNly IMT in IN perlorlMnN 0t IM work IOr which Ihif permit is OWed I shall employ persona EYDI.CI to waLman.a CONVENayy,/ tion laws UI Y.�i Lt The apWkem must CW>ler as mOuirW Ineprctbne. Comdata dowing on overt side. Slgped A �,O•f.G.. . e �� Tale: 1Mzr.N- d"OR Dna ,,.._ , >$ e t[ a ` w s 15'p 4 ,� .E l FOR(/p EPA RTMENT USE ONLY } 1LLF .�O'L L v d Apelicebn tAttested by -- rA Dn. Area 2_Z12 ' - V Finn Inspection by _ Date i Pit it Waal Inspection by D.•u a .•x r n to y y, AddbbNl Lem—MIS Q•YC UANlJ" GCL61/i.r-`Ke_� Applieart A.turd all OOP"' tu. BAN JOAQUIN COVNTYP"aLIC 111"771 85RYIC89 < S F7lVI RONYSNTAL HEALTH DIVISION PeRYIT/SERVICSN ee5 N SAN JOAQUIN. P 0 NOR 2009. STUCK1'ON. CA 96201 PECHVEp aY DAT[ PE 11 NO t INFO AMOUNT DUE AMOUNT nEMITTFD _ F.+ � . L� L' — . .. •7 3'L$'4( - ir3Trry�'}'tj qXi N Salmi, t .. '.,.,,;;t5/.t.t,�w._.:.-6v.r.a:n:,'4.n+.if+y.�xwv.:-.--raw-aw`•mm..uceyr-j�LeOK.� R t K,+��.wcwn'VL�s✓.wasi✓hG:A.`ce.LUJ. Iia:�.a-..,r...�. ,. '•n?t <z 7 ` a