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APPLICATION FOR PERMIT <br /> SAN JOANVIN COUNTY PUBLIC �2F- <br /> 445 <br /> SNVI$ONL.IILin <br /> TH DI I N SAN JOAQNE (20 ) <br /> P 0 BO% 200TON, C <br /> PERMIT EXPIRES UQa <br /> (Complete Triplica )���� <br /> Application It hereby slide tc Ban Joaquin County for a <br /> he <br /> to construct an 41111 if a Sows of Berl <br /> application is made in ceayllence, with Dan Joaquin County Ordinance No. 549 and <br /> Joaquin County Public Bealth gService.. <br /> �a► r11_ CitK Lot Biu/Acreerrfe <br /> Job Adders T�O���� c((x��. <br /> T V I�Y..QA- Address 1 O I '`•"""" Phone 'y _ 17 <br /> Owner's Name �"` � ,J <br /> �, . ' Pd Bal 76 7 L 3 z£1 L z Phone 3b 8 SPo <br /> Contract K� Atldress y r License No. <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT I1 DESTRUCTION ❑ out of Service Well <br /> PUMP INSTALLATION C SYSTEM REPAIR Cl OTHER ❑ Monitoring Yell C <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial C Open Bononl ❑ Manteca Dia. of Well Excavation_ Dia. o1 Wen Casing <br /> CI Do nosuUPrivste Ll Gravel Pack ❑ Tracy Type of Casing--_-- Specifications <br /> 1'I PWNit 1'1 Other ❑ "is Depth of Groul Seal Type of Grout <br /> I I In"1000 —APMO-. Depth I I Eastern S.,/ace Sext In,Wsed by �] <br /> Repair Wort Dons C Type of Pump H.P. Stara Work Done <br /> Wel Destruction O Wall Ole rusu f Sealing Material i Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION REPAIR/ADDIPON I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> svailable within 200 Iset.l <br /> Installation will serve: RssMcal <br /> ines Confunm _ Other <br /> er <br /> Numbof living units: /� Number of <br /> Chwactw of Will to a depth of 7 ten: Water table hath V <br /> SEPTIC TANK - Type/Ml9 r Capacity No. Compartments <br /> PKG. TREATMENT PLT..❑ / / Method of Diyw"i <br /> Distance to Merest: Walla,7.('' Foundation_�._ Property Life ' <br /> LEACHING LINE No. 6 Length of lint _ Total langth/airs X <br /> FILTER BED ❑ Distance to rearm: Wal—.16 FOurllfatron /A/f Propnty Line <br /> SEEPAGE PITS }y Depth _Sir. Nymber_ <br /> SUMPS LI Distance to arrest: WalTd �F Foundation ProPxrty, Lina s- 't <br /> DISPOSAL PONDS C <br /> I hereby certify that I have oraparad this application and that the work will be tone in accordance with San JWquin county ordinances, state laws. and <br /> runts and regulations of the San Joaquin County <br /> Hama owner or licensed agent's signr lura certifies the following "I certify that in the parlormance of the work for which this parntit is issued, 1 Mall not <br /> employ any person in such thinner as to become subject to workman's compensatwn lawn of California."Conitacow's hiring or suDconusctkp signature <br /> cenitlea thefollowurq: 'I certify that in the perfomlance of the work for which this permit is issued. I shelf employ persona subject to workman's cempanN- <br /> ti0n Laws of California." <br /> The applicant MI for as u'r inagctione. Compleu drawing on reverse side. ` .off 9 <br /> Signed t I Title: V, P Date: — <br /> FOR DEPARTMENT USE ONLY (•� <br /> AplikAtion Accepted by � Date Area�•�__ <br /> t9w Grout Impafctito/n by ��',,`� ! Deu✓� Final Inspection by Dne y <br /> / C <br /> AdddoMl ommintY: air //.4✓ <br /> -- Apr,llcant - Return all copies to: San Joaquin County Public Health 3ervleen ��T) <br /> Nov i"turental Health Permit/Services 443 N Sao JoaquleP oa 2009, Btkn, OA 95 0 <br /> AMOUNT Due AMOUNT REMITTED Ili' RECEIVED by DATF P�ESRMIIII'NO. <br /> . <br /> Ch 13.24 LN.11x111 l �.Sl l .)qj I/4 f/ � f <br /> IN u.al "'777 "`..."'WWW <br />