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APPLICATION � <br /> { SART JCQQUIZ COUNTY PUBLIC IML SSV CBS <br /> )41 <br /> ZMIBDM=TAL HEALTH DI' 1 I01 t <br /> 445 N =1 JOAQUIN, PHONE (209)1468-3420 <br /> .. P 0 B0:8 2009, - STOCETOW, CA .52.01-t <br /> �1 <br /> (Complete in Triplicat <br /> Ar7llcatioa lo hereby =Aa.to San Joaquin County for a permit to construct and/or instep. the work berein described. This <br /> ag'r,lieati= is tido in ee:�lionee with Hua Joaquin County ordinance go. 549 and 1962 and tl* Ruleo and Aaaulatioma of Sa.n <br /> Ja quio County Public Hcn]th Sarricen. <br /> Job Address ( -� +��' ! City Lot Sire/Acreage <br /> IL <br /> Owrai a Ne rtto Address Phone <br /> Contractor csY dress 1.4 6ell NYt 4.,.-Pnom� <br /> TYPE OF WELL/PUMP: NM WELL O WELL REPLACEMENT n DESTRUCTION Q Out of Service Uoll <br /> Ih PUMP INSTALLATION G SYSTEM REPAIR D OTHER 0 t:onitorina Hell ❑ <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 indurtrici ❑Open Bottom 7 Mantoea Din. of Welt Excavation. Dia. of Wed Caging <br /> 11 DomeetWNivata Cl Gravel Pack 0 Tracy Typo of Casing Specifications <br /> 1'1 Public t.l Other fl Delta Depth of Grout San: Typo of Growl <br /> I 1 Irrigation _Approx. Depth 1 1 Eastern Sudaeo Seal Installed by <br /> Ropew Woos Dora 0 Typo at Pump H.P. Stow Wort Dona <br /> I WCn 0ectruction ❑ Won Die motor Saolina Mterial G Depth <br /> k Doth Piller tatorial b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION INo wptie syadcm p2rmittod if public ccvxx i3 <br /> within 2W fgt.l <br /> IM1LIletlprl Nt.OI LINO: RnCO 4 Commercial_ t7iller <br /> Numb=of fivinp units: Nurrtbor of bodreoms <br /> Chtrt tt=of Boll to a pth of 3 toot: Water lebb 4--pth <br /> SEPTIC TAROK O Typo/mfg Canpoaity ��d � No. CottepuM= is Z- <br /> PKG. TREATMENT PLT.❑ K / Method of Di�Oer� T2 <br /> Ol truce to nocreal: Well � Foundation g Property Ling ,�S', r !v <br /> LEACHING UNE Cl No. 6 Length of 11nas _ Total langthhfto <br /> FILTER BED 0 Distance to nearest: Well Foundation Proporty Lino <br /> SEEPAV_PITS I I Depth Site Number <br /> SUMPS Lt Dostrnco to rtr.==-. Wca Fourwation Prol=ny Lim <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I hevo propered this application and that the work will be don*in accordance with San Joaquin county oftlinaneoo. cWto tows, and <br /> neo cnd rceulctione of iho Son JoaWin CoonV <br /> Nomo own=or licenecd c,,,m's c*wuta onvulico the following: "I certify that bt the performanco of the work for which Iles pmm c i=icd,1 d%O not <br /> enVdoy any pereon in r..ueh rets a3 to brown ctabpct to workman's componce0on lwxo of Cclifomea."Contrecter's haing or cub-conuccto cignaturo <br /> eortifiao the faCawing:"I Certbfy thea in thin portormenco Of tho work for which this pormit is it:oucd.1 shutl employ por=n aubmct to wwkm n'a eornpertsa- <br /> tion Lmra of CeMornio." <br /> Tho 77#jD <br /> for cg 'rod inzpgctiom. Complete drawing On roveroo aido. <br /> Sigrt^Ji � _ :.►L..�..� ,�is Titch: "'_ Data: Zze"A*e <br /> FOR DEPARTMENT USE ONLY <br /> AppEmtlon Accepted by -�� OCto r/e fl Aron_oZ/ <br /> frc or C-rovdt 4nepcotion,by Oats Find tncvocteon byL4,4- � ,Pg/ <br /> Add6tiond <br /> Applicant - Return all copies to: San Joaquin County public health Services <br /> Bnvirour entaI ort Health Peron/Services <br /> j 445 A San Joaquin. P O S2009. Stkn. CA 95201 <br /> L� j, <br /> -2. / t�f0 MOUNT DUE AMOUNT REMIMD CASH RECEIVED OY DATE "�Ve�/ ✓ <br /> EK N.� <br />