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APi`,ICATION FOR PERNII'
<br /> a SAN JOAQUI.N COUNTY PUBLIC HEALTH SERVICES NAY
<br /> 2
<br /> �. ENVI:IONHENTAL lIEALTii DIVISION r'.n,' -
<br /> P 0 BOX 2009, STOC;EI.JN, CA 9501 PF IUT,�r F/4CtJ
<br /> fl I! (209) 468-3447 /Mj7-,,/SF �, f
<br /> '' l?ERlaIT SXF'IILIsS_1_
<br /> YEAR p$QL�7 :fE ISSSISQ ( [ O �M
<br /> (Complete In Trip]Icate) �`✓� ►LJf
<br /> 1
<br /> Application Is hvreby tesd+t,to Baa Joaquin County for a permit to construct and/or Snatall the vork herein described. This
<br /> E€ S application it al In eomplsante vlth Sen J04Q41n Caunry Ardlnanc• No. 549 and 1862 and the Rules and Reculatlons of San
<br /> ,1 d Joaquin County Pob1Se Health 8ervicea.
<br /> J -
<br /> Job Address �v 7 ��1• .1L, Pz, City .�� O Wtt Size/Acreage
<br /> ,...
<br /> All
<br /> S ��{ — .. rl�'tl . .-._ . R• ..[5 70 Fhone _
<br /> 2{ owner's Name x' Address Fb
<br /> k' I Corlfactor u4tii.r Address. e ,( Lead »C?_yt-Crn3e No.�y1��.
<br /> TYPE OF WELLIPLIMP: NEW WELL 0 WELL REPLACEMENT FI DESTAt:CTK—N 0 Out of Service IFe11
<br /> PUMP+NSTALLATION 21 SYSTEM REPAIR ( � OTHER C3IWnitoring Yell
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. - PROP.LINE ..��-
<br /> a
<br /> FOUNDATION AGPICULTU8E WELL _ 0?>1ER WELL PITS/SUMPS �.
<br /> � 5
<br /> }NTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> �•f i fl Irl�dyptnat C]Open Oossom 0 Manlere Urn.of Weal ExcavationDia.of Watt Cask49 t
<br /> 441 omeericIPrivaie G Grevct Pack L;Tracy Tv-pa Of Casing_ Specilicolions
<br /> "6'''7 la P44bliC I:1 Other 0 Delta 01101h of Grout Seal TYM of Grout {y�
<br /> CJIrrvJstiort '.I A;dprps. Depth 0 Eastern Surfece Seal Inetelled bY_-_.�--�- W
<br /> Repair YYoril Donn /Yoe of Pump H.'._ State Work Done
<br /> . :
<br /> Staling JNtwria.l i DVth �}
<br /> I1
<br /> WON Oestnrctbn Q Watt Diamalar
<br /> y`;`�P�r ° Piller Dsuterial L Depth
<br /> M,JI Lk'plh— _—
<br /> t;Ft
<br /> TYPE DF SEPTIC WORK. NEW INSTALLATION L3 REPAIHlAUUITItIN Cl DESTfil7CTkON f.1 INv sepr4c eyptem parmilled N publi0 liewor it
<br /> available within 20D teat.)
<br /> � h * inatafill1 e0A will srve: neiidersct,_.. Co-t"rcial Other
<br /> Nunbtr of living units. Number of badroo I —
<br /> Fir+l Water tables depth
<br /> •• Charapttt p1 00 to a depth of 3 feet:
<br /> y''a •#�a; y SEPTIC TANK. C,I Typs/Mig — — Capacity_ No.COmpartts "til #t
<br /> Morhod of 0*50"1 :I
<br /> rj �r i PKO: TREATMENT PLT,Cl r
<br /> Dlstanee to nearest: Well FpundaGon Property Line.
<br /> LEACHING LINE 0 No. 6 Length O!fines - :TOlal length/ii.te .(
<br /> �,� ��{�,'ya'�y��► 'f � 5t 'r FILTEI+EsEO CS Distance to neareu: Well Foundation 1 Property Line
<br /> SEEPAGE PITS I 1 Depth Sire M _ —_ .� Number
<br /> 'SUMPS', LI Distance to nowesr: Won _ foundaiipri Property Line
<br /> i,il4 ff't,�1e tt _
<br /> DISPOSAL PONDS {l
<br /> c s, y f hereby certify that I have prepared this application and It4al the work will ha done In accor,ance with San Joaquin county ordinances,!sate Laws,and .
<br /> nrNe.and na2ulat:ons of the San Jpaouln County ]
<br /> Home owner a t;tsnsad agent's signature tertihes the follamng: "I Comity that In the peftotmence 0:the work for which this permit is i4Wad,t shelf rat- p
<br /> amptoY aeiy pifiamin such mgnr,er as io become wbpct to wotkmsn's compcni6tion Lows of Cofifornia."Contraitor's hying or ruD-Sontraethtg siynstu».
<br /> 5
<br /> i, ;.� �r�.r� j t �, h- etrtifirr�thm,fottowir417:"i r:ernh'that In the yrrtarmencMpl she work for which.th+v permit is iseuad,S shall employ persona subject to workman's Compansa•
<br /> Inn is at'CaSllJfnia.'
<br /> II ; Ina iFpllean!,'mrst call iequ:red ipsOa,S�tbni. Compltte drawing on reyaray.oda.
<br /> R `/J I ))
<br /> r n , $;gned X_ Title: Delp'
<br /> 1 i
<br /> FQR DEPARTMENT USE ONLY
<br /> 3 9 m
<br /> ty '� .L rilE� Applkatkn Accsptad by. �U�/�La:� - - _ Dal t Ana'o—'
<br /> ;h r }JSi7i4S , y
<br /> st°rfi' �• yi'It or Oraut Inepeetbn by. Date_ Final Inspection bY_ Dna
<br /> ,•.F;?{EYiC��,�' ffi '�i4 Additional,Comments: ,
<br /> ??
<br /> dppllcarit - Retura aZS COpteato: SAN JOAQOIH COUNTY PUBLIC HEALTH BHAyICBS .
<br /> ENVIRONMENTAL HEALTH DIVIBIOH PHRialT/SERVICES
<br /> 446 H SAN JOAQUIN. P O ROY 2009. BTOCXTON. CA 05201
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