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APPLICATION FOR PB"M I T <br /> SAN JOAQUIN COUNTY PUBLIC RBALTR SBR Ift# <br /> EYVIRONIEBNTAL RBALTR DIVISION <br /> P 0 BOX 2009, STocsTON, CA 9520 FAC# <br /> (209) 468-3447 <br /> (Complete in Triplicate) <br /> APPlicatloo is hereby cede to Sao Joaquin County for a Perait to construct and/or install the work herein'described. This <br /> applieatloo 1e aede Sa eettplieaoe With Ban Joaquin County Ordinance No. 549 am 1862 am the nulee and Reguiacioae of San <br /> Joaquin Couaty Public Eealth Services. <br /> Job Address :Z-3-7 /U1gp Aosd ep as 7 Sh <br /> Ciryr. <br /> ��Y' �C•J Lot 8lse/Acre e a <br /> OWrrter's Name Z! _2 ,{1 r 1G Address '2373,iJAI?z PS4 PD S'T7Yr'7rjd _ <br /> Phone <br /> Conlractor F►t) nili /n678L4,ar6v�cc. Ra <br /> Address-----.;:„- Licence No.G.�i'7BG Pn <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION O Out of Service Yell <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER � Gn MOR}_�ring Well O <br /> DISTANCE 70 NEAREST: SEPTIC TANK Jam. SEWER LINESd�./d DISPOSAL FLD.,�(�,r PROP. LINE <br /> , LINE <br /> FOUNDATION _4 AGRICULTURE WELL j&,4_ OTHER WELL ZSO� PITS/SUMPS _&A <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION <br /> SPECIFICATIONS Industrial O Opn Bottom OManca <br /> Die. of Well Casing Domca/Privets a Gravel Peek O Tracy Type of Casing /AO public Ll Oliver Specifications <br /> frl <br /> l <br /> 0 Deus Depth of Grow Seal <br /> Mt Type of Grout CAr'r kJj <br /> CI Irrigation Approx. Depth �Easrem Surface Seal Mstalled n,. rf2 , <br /> Repair Work Done O Type of Pump M.P. Slate Work Done _ <br /> Wag Destruction 0 , WW Diameter Sealing Material a Depth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION C1 OESTRUCTtON G INo seplie syst200 feet.)em permitted it public sewer is <br /> Inalsgnion Will serve: Residence_ Comrtwwavailable within l_ Other <br /> Number of Wing unite:_ Number of bedrooms <br /> Character of soil to a depth of 0 test: <br /> SEPTIC TANKO Type/MIB Water table dean <br /> Capach No. Compartments <br /> PK4. TREATMENT PLT.O <br /> Method of Disposal n <br /> Distance to nearest; WON Foundation Property Line <br /> LEACHING LINE O No. A Length of Mas Total Isopto/sue <br /> FILTER BED O Distance to nearest: Wag Foundation <br /> Property Line <br /> SEEPAGE PITS I I Depth Sire <br /> SUMPS _ Number <br /> L7 Distance to nearest: WW Foundation Property Line <br /> DISPOSAL PONOS O <br /> I hereby csnifY that I he”prepared ibis application aro Chat the work will be done in accotdanca <br /> rules and-regulatiaa of the San Jwgwith San Joaquin county ordinances, state laws, end <br /> Wn County <br /> Horth owner at Faonsed agants signatuto O"rNs the 1pgpwin I canif that In the ,` <br /> emPbY any porton in such manner as to become w .• Y Performance of face rn Inn work for whim This permit is issued, I shag riot <br /> C40064111 tM 1 bleat la workman's COmpeneatier laws of ed.I$hall ploy tors ntrinp or sub-contracting tipnatura <br /> tion laws o1,CWfOmAs )CSNty that a IM penormence of Me wort for which thin permit is cawed. 1 sMll employ persons subject to workman's tompensa• <br /> The eppgean e M r uir inspections. Compete drawing on reverse side. <br /> Tits: _onA2 jj//fore„, <br /> Signed I. { <br /> Dole: <br /> FOR DEPARTMENT USE ONLY yyq <br /> Application Accepted by Data '' y/L�� Area <br /> Pit or Grout hwooction by Date Final Inspection by <br /> �r Dau <br /> Additional comments: A -).E -Z LT 6Qr <br /> Applicant - Return all copies for SAN JOAQUIN OOWITY PUBLIC HEALTH SBSVICS9 <br /> &1viatEumAL BEALTH DIVISION PIT/SBRVICBSur <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCXTONERM , CA 88201 <br /> fEE AMOUNT DUE A 350 <br /> Wf0 AMOUNT REMITTED CASH RECEIVED BY GATE PERMn'NO. <br /> t�Iirr UtY. <br />