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ADPLKATI ON <br /> � 1NT <br /> Y <br /> -PUEL"Ei�r �1{ ONMENT �SP_" <br /> SAN)OAQ1IN COMMALIIPAT-79A � (209)46$s— <br /> 34I2C0 <br /> $*VIRO,'N•E%TI, <br /> LPE � 09,SPECIAR**_ X 2Q <br /> ❑ � ! <br /> Q � u <br /> Q <br /> 4.. (Complete in !Triplicitte <br /> 1 llcation i• hereby made to Sas Joaquin County for a Permit to-eo�atri^'---""• bC.vorti Fi�41n described. This , <br /> appllcatioa ie wade in corvliarce with San Joaqutn County Ordinance NO, 5149 and 1f3u3 and the Rule■ and ResuLtivns of San <br /> 1 .Tosquin County PublicReam Services. <br /> c r uctl,�h , <br /> ('�I� <br /> _�� ..Jt—....-~ Luh Si i./Ac rea![e <br /> Job Address - -'--- <br /> Owmf's Name - —" <br /> S CordfAtta 40No. �! <br /> NEW WELL CA M1El.t REI'tACEPaINT 11 DESTRUCTION is Out oC service Well Gl <br /> TYPE OF WELLIPUMP, <br /> PUMP INSTALLATION C SYSTEM AFFAIR �` OTHER G <br /> MonitorlrW Well C) <br /> { i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP LINE <br /> FOUNDATION AGRICULTURE WELL __ OTHER WELL PITS/SUMPS <br /> tt i <br /> f <br /> INTENDED USE TYPE OF WELL PROEM EM AREA CONSTRUCTION SPECIFICATIONS ry <br /> }Industrial U Open Elortom i'1 Mamsca Dim.of Weu EacsvahOn Dia.of Wen Call", a <br /> 1 f I Ownestic)Private 0 Gravel Pack Il Tracy Type of Csung__—___ Specifications <br /> f'l Public fl Other 11 Delta Oeam of Grtw1 Seal Type of Grout <br /> I!InigaURn Ammon. Depth I I Essiom Surface Serl Installed by ` <br /> Repair Work Done I) Type Of Pump H P, _---- State Work Done„ ' <br /> . .wall Doolruetion 0 Won Diimaler 6ealirt3 Material L•Orpth <br /> Depth Filler Material i r+epth .. <br /> TYP_E0 F SEPTIC WORK: NEW INSIAI.L.ATION I 1 REPAIRIADOITION OLSTRUCTION I I INo"plot system Peemlled d pipes srwse a <br /> {/ ovs4bin wNhin 200 f"t.l <br /> InataRatlon wm esn!e; Rraidence n Com mmiol Other .,.. <br /> Nurrlber of Elving wife: J_ 1fi+mber of bedroom/ �. <br /> Chariofef of mil to a depth of Pool: Wolof table,depth ,. <br /> SEPTIC TANK C3 TYpheh/Mfg r Na.Compa <br /> p 'Cl Z f9 nnvnu <br /> PKO,TREATMENT PLT.0 klelhod of Dispose <br /> Dlatance to nearest: Wend Foundation! 0 Property Lina_ ey .� E <br /> LfACHINtr LINE -Cl' No.A Length of lima �_ Totei Iength/sire <br /> FILTER BED Y 0 Distance,to naanu: Weil Fcuiwetlon -1 �.Properly Line -- <br /> 5 h <br /> es�YyS if r - t <br /> s I5 s SEEPAGE PITS 11 Depth Site Nuenher Z^ <br /> { a <br /> 4' <br /> SUMPS <br /> t <br /> SUMPS ; L1 -Distance to nearest: I Wen Foundation O PropertyL. <br /> L _1 <br /> 4r„ �;Y5rjil DISPOSAL PONDS ❑ AO X I O�A_ V✓E'e'l <br /> !hereby certify that I have prepared this appkcaipn and that She work win W done in accordance with San JaWuin county adlnM:t+s.festa Was.end <br /> roles and regulations of the San Joaquin Comilir I <br /> Noma oyvner or iicenead agent's signature candies the folbwrng:"I Candy Thu in the perlamanu o![M wdrt la whish this permit ki'saWd,1 sloes not „ <br /> ?r -j •.1 enlpld'V any person in such!fender as to beconw subpot to woikn-an's compos"Iron laws of CaldOlma."Contractors hying or sub-COMIacrirq sit;"turd +j <br /> OlinKia ft lonowirq:111 Certify that in tel performance of the wort lot whrei+this perms 4s issued,I shall amiplov peroone subtecl to workman's eomxw"- ; <br /> 'fkan laws of CMUomle." <br /> iv�I C The appllesnt MMI a.COMP410 drawtng on reverse tide. - I <br /> ,s 4 <br /> Smiled 1C:,:_ Date: s Y, <br /> FOR DEPARTMENT USE ONLY <br /> Dau r <br /> l:',`"4;}y_,;:;•'i>` AppGcat Aeeaptedby = Are ..._ x <br /> `l� �bY' she mal tnspection by ,- — e Date i. <br /> Addhl"Comn+eirm <br /> w <br /> I M r a,1 c• -- - <br /> -� Applicant - Return all copies to: gen Joayuln CossntY Itihllr. flrtatth 3crrlcen ;1 <br /> ts¢�r L'erlronaen hal 1lealflo (�arralt/8erricaa <br /> aeS 11 San Joe4ute, i' U Ho■ 20". ytkn, rA 111701 <br /> Ftf. AMOUNT DUE AMOUNT 11EMI7TL0CISH RECIrykD ey DATI FOAMY NO, <br /> .:� .ElSitsaratv.r..trf, a �U NV— 1� ;q3 f <br /> 1 <br /> t <br />