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1'1:.IISIIT Exj'1EtE�_1_Y.,Eit11?_�jii:l�)1,1'!t: 1:iSL'}:i!
<br /> lCory:cu: IL
<br /> Application Is hereby aesde to San :064uln County for a permit to construct end/or Install the work herein described. TAie
<br /> application Is =41 in ccvvllan:e with San JasQuin County Crdinance No. 549 and 1852 and the Mules and AeBulAttone of Ben
<br /> JoequiN County Public Nsalth Services.
<br /> Job Add,ess oL 3 79-t W 7)i a%'/F. S z ,_ City �O r Lot Btte/ creage
<br /> Owner's Name 1+_AA L.e E/1Ri l(L_ Address Ir 5 r 3 4!;eC t `X Prions 34,7-Yl 7
<br /> Conl,scly rltYO f. /L•n�a _A•,d,esl �.✓_.��:.i�.Cr _L-cerse No 5/Jrz7s PhoneJ=3Y7 i
<br /> TYPE OF WELL/PUMP NEYV AELL �r LYELL REPLACEMENT i. DESTRUCTION Cl Out of Serwtce Nell
<br /> PUMP INSTALL,Th)t[ C1 SYSTEM REPAiR ; OTHER C) Monitorlr.B Well Q i
<br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES _ DISPOSA.FLD. PROP UNE `
<br /> FOUNDATION AGRICULTURE WELL __ OTHER WELL PITS/SUMPS
<br /> INTENDED USE TYPE OF WILL PROBLEM AREA C_ONSTRJCTION SPECIFICATIONS
<br /> (1 Induslnal U Open Botlorl C MAnlecs Dia of'Wait E.c8.6lon_ Do of WON Casw.p
<br /> Li Domutrc/Pnrele G Grs,,,v Pau 0 Tracy Typo of Css.n 3
<br /> g--- Spec.l.cal.one 1
<br /> O PuDt.c I Other J JOR+ Depth of G,ow Seal ,_ Type of Grout
<br /> M lu.Uel,on —_Ap{wo. Depth 0 Esalsfn Swfice Se.1 Inslacea by_ t
<br /> Rspew Work Done U Type of Pump H P _ Sta'a Wo,k Done
<br /> Well Dettruclgn O Well D.ame'a, —_ Seellnft Material i Depth
<br /> Depth Piller Material a Depth 1
<br /> TYPE OF SEPTIC WORK NEW INSTALLATIONX. REPAIR;ADDITION DESTRUCTION u (No sopf.0 syslam tool—fled 4 p,.Dee sews,e 1
<br /> a.ataG4 wnn.n 200 lest.) }
<br /> Installation vwd em
<br /> ern Rss•oance Com ,.,c-al_ Other
<br /> NumWr of bump units _1_ Numbs,of Dad,Jome
<br /> Charente,of eoJ to a depth of 7 leer. �.'I.�< %��s y /f,a.•,
<br /> I
<br /> Water taps depth
<br /> SEPTIC TANK
<br /> w
<br /> 2 Type/Mfg , /•_Iia ; Cspaatr I i--- No Cornwnmsnte J '
<br /> PKG TREATMENT PLT.Cl Malhnd of Disposal
<br /> O,stonce to nes,esl Viet!_1_1L_ Foundet•on _ // Property line _7!
<br /> LEACHING LINE L No •Length of t,ret TOIa'qr gin yin Jr 7c*'
<br /> FILTER BED CI Distance to nea,sit v/en_ZCt_ lfo.ndlban ;e Property Line +N
<br /> SEEPAGE PITS I r�
<br /> . DeDlh 2�. .S.a --At L ------ NumDe,
<br /> SUMPS LI O.stance to nearest Wall—tea_ Fowndal•on 1!! _ P,operty line 2If'
<br /> DISPOSAL PONDS ❑
<br /> I he4Dy Comity that I ha's prepared Inif and Inat 11.1 Sup,. wA Ds done,n accor Since wdh San J04Qu1n COLrHy ordmances.state laws. and
<br /> rules sr•d rapvlal,ona of the San Josoum County
<br /> Homs owns,a I•censed agent e pgnslu,e cs,.Les the to�,—rg I cone,Ira'.n Ira pe'lo„.ar.e o'tris wo,. for which this pennt-.aawd•I"N not i
<br /> employ any plIforn.n Such mann,at 10 become auDieG'Ip won r.+a,1 Cumpensaf.on laws of Cal.IJrn.a Contractor s hiring o,su4conlracl.n9 eignalufe
<br /> CerUf.el the fc Kowmp "I ce,Lfy that,n the purl Crmance L'Ins n(r Ic:wntq Ih 3;rerm t to•U�ed I viii employ persons subject to wor►nyn.e COrrlpenaa I-on lows of California" 1
<br /> Tn$applicant nwsl salt la AN rpuued nspeel ons Compltle 0-s .nl on re.sraa este.
<br /> Signed X_�3`. /� >..> — T-1-4 _
<br /> Date:
<br /> FOR DEPARTMENT USE ONLY
<br /> v rim �a-�' 13 t
<br /> Application Accepted D ,- � L' Dale Area_
<br /> Pd or Grout Inspection by _ Dace_ Fa,ol lnspecbcrn by Date i
<br /> Additional Comments _ J
<br /> Applicant - Aeturti all copies to:
<br /> p tiltf JOAQUIN COUNTY PUBLIC f16ALTN 9CAV1C83
<br /> ENVIROMNEHTAL HLALTH DIVISION PERMIT/SERVICES
<br /> 443 N SAN JOAQUIN, P O U04 1009, `JTUCKTON. CA 95201Fit
<br /> �yS
<br /> INFO AMOUNT IDLE AMOV/,i R(Ah TIED CaSN R[CPYED BY DATE PEAM11 NO
<br /> . IM 13241111v ,••t,
<br />
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