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APPLICATION yo ,tg[T �1c �-/•'J Sa-, .� <br /> ce l� tea <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> MWIRONRL-NTAL IIEALT11 DIVISION <br /> 445 N SAN JO.AQUIN, PHONE (204)468-3420 <br /> p O BOX 2009, 5TC''Y.TON, C1 95201 <br /> �,R1EIT B,XPIRES 1 YE-lR I'�Q _ <br /> (COMPL::te in Triplicate) <br /> u,n coos for rmlt construct and/or tnstAll the work herein described. Tnis <br /> Application is her*try made to Sam JOA(lY ly y Ae latione or flan ' <br /> s kltation is eUde ie coapllence vlLb Ba.n Jo■quln cowst ordinance xo- 5J.9 and 1862 and the Rules aAd <br /> Joaquin County Public Raalth Serviaei. <br /> r 4'.r r, I Lot `J1ae/Aeras!;a <br /> 7�. <br /> Job Address ----+-�- Cary - <br /> _ Phone ......r''7 -1_J—'7 <br /> Addiast L.��1K-.-• <br /> Owrfar's Name <br /> /Y/ phone �i7. •/C r�i I <br /> I -�q''•-' ins �'- N 'L.L'Cenie No. : <br /> q Uacltr Lt" •..:1'. Address. <br /> �,9 I-• - TYPE OF WELLIPUMP; NEW WELL WFC LL REPLACEMENT Cl DESTRUCTION Ll Out of t rin L.,11ConL1 I <br /> OTHER f':! Mnniorltt{ 1 `11 C7 i <br /> PUMP MSTA.LIATION ❑ 5'ISTFF.S REPAIR it E <br /> )'/' SEWER LIY,ES DISPOSAL FLp. ' PROP. LINE �.�. <br /> DISTANCE TO Nf lH6$T SEPTIC TANK ��'FOU �' — AVAICULTURE WE.L OTHER WELL PITS/SUkAPS <br /> SEPT OATION _ --_�--- <br /> r <br /> INTENDED USE TYi'E Of WELL PR08LEAE AREA GONSTRt1CTION SPECIFICATIONS <br /> v pia.of WN1 casing <br /> „ s _ <br /> Ll indul;osl fJ Open Bottom C7 Man[aca Ois.of WnII Frcavrtion�'1: Spacilications /F!' <br /> 'u1 Tracy Type of Caa»q_ -.--. <br /> 4ae"wIClPrlvate - '�Gravel Pack. r type T est Grout -+ v <br /> 3, ` P11bfe fa Other (I Delta <br /> Depth Of l.'o-r'?eat f. <br /> 1idY{�Appras. Depth I I Estlain S,vfsce 5sal Installed by N <br /> ��t r - you IfligaliOn:;Y` <br /> / 5 H.n, � _�_ Suta Work Dons <br /> } _ - Repair Work�11e ❑ Type of Purnp 8e911rrA Mnterlal a Depth <br /> WEH Destruction ❑ Well Dianwtst <br /> ft liar Meter inl i Depth <br /> c> _ Depth- -. <br /> Y- <br /> x r TYPE OF SEPTIC WORK: NEW INSTALLATION I I Hr;rAIHrAO01'ION I I hCSTHUC11gN I I ;ailabls'witl+irt 240 fesi`)ad d p1rblK Sower� ` <br /> r•4 ` <br /> Installation will Serve: Residents Gommarciet..,.�• Olhar Y <br /> rxr Num)er of bedroome_ 4 <br /> Number of living units:..._ "" Water table depth <br /> zl%vaclar of No to a 4sprh of 3 fest: Capacity No,cemy+artrr»nta _ -- <br /> SEPTIC TANK- ❑ TyWIFAfg <br /> Method of DiEpasa11 y. <br /> PIKG. TREATMtNT PLT,❑ Prrlparty Line_ f <br /> 1' is <br /> Distance to naaestr Well Foundation <br /> Totn1 length/siir <br /> UACHING LINE ,❑ No.8 Lanpth o!tines --•• ProfierlY Lits• ----- <br /> r Msunea to W94111441:FILTtWell Foundauen�_�� <br /> cl Plumber <br /> SEEPAGE PITS LI Depth -�-Iiia Property Line <br /> L. {]lrtence to nSeruet-. Well <br /> SUMPS <br /> Foundation <br /> tr:,* <br /> DISPOSAL PANDS .❑ <br /> I hereby certify that I haw prepared thio apphcatron and that the work wM be done in accofdanca with San Joaquin county ordinances,vele latera,and <br /> •:�e s ruses and reyyulllgm of the San Joaquin County <br /> Hoare owns:M licensed v"ni's•signature csnffkw iha!SAriwinp:"I!artily that in[he performance o!the worts}or whish thio permit is issued i shaft not <br /> hiring <br /> atWlo,any pawn In aueh rr*nrW as to become taclimi;Signal If <br /> :,rbjec[[o wcrkrran'a wrnofnsation iavra of GHifI ShEl,"Contra gl@ona subject to workof tman'aa compenSe- <br /> rr+ J <br /> s ! vert that in tM pr,rlormarsca of Ihs work for which this permit is issued,l ahGlt employ W <br /> y ..cc. ITiesliNFnMwing: a Kl' <br /> fc ry R t:sr Ilon Ian a <br /> lk ms.CtmC�s[s drawing.1^.reverse side. <br /> + l/ <br /> The applke'�t r.w�6a1r for M r.+d�ired I�' _ <br /> 1•-;tl'�; t)-r c ,��/i.0 -1 i•iiia:_. ? Dsta. <br /> -' <br /> Signed / <br /> x Lf <br /> FO PEA RT ENT UuE ONLY 7 j <br /> �J�r�� Daae I '• Ana_ m <br /> gppiicstlon--/,Ceeated by - G �� _ i� <br /> Care Final ln►paetion t1, Date <br /> Pit or rout Inspeetlon byn 'r <br /> $, Addhlonal tour~s: f�`�,., •��' G c a <br /> x '3 tn �'ltr� <br /> ant - neturn -._t eopiee to: ...1 Jo nsuln County Pnb11c 11ea1 Ch Services <br /> ApeslicEdvtronmental Poalth Pn rmi ti 9ervl eve :: ,' � <br /> 4.25 N Sae Joaquin, P C Box 2009' Stkn, O/. 85801 � C: �{ <br /> Ittr:ilv'1D aY DAYE <br /> A <br /> P}FRf73TEO CAS" <br /> NOUNT DUE AMOUNT nEMIT <br /> tN 11 14 1n9V.1 <br /> O�_ ( 3 ! <br /> fm 1618 ��-1—max.•-=--�- <br /> , <br /> t <br /> r :: <br /> z <br />