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PLI CAT ON FOR PERMIT <br /> SAN JOAQUIN COU1 TY PtAtIC HEALTH SERVICES <br /> ENVIRONMTAL HEALTH DIVISION -- <br /> 445 N SAN JOAQUINI PHONE (209)468-3420 <br /> P O 13O% 2009, STOMON, CA 95201 <br /> PMIT W I RE U 1 YEAR FR9V DATE ISOPQ <br /> (Complete in Triplicate) <br /> Application is hereby made to 8" JdRquin County tor a plrmit to conotrtict bnd/or install the work herein described. This <br /> application is made in ec4lianee with Ben Joaquin County Ordinance No. 51+9 And le62 And the Rules and Regulations or San <br /> Joaquin County Public Health Bei-vicea. <br /> Job Address - 36 'C 7 S r4 City WPLUt" Lot Size/Acreage t'OQX 12S <br /> Owner's Name Af 5 Cd`t.Ad,R Q Mytet.f"Address -e" 4 actk V r- _ Phone zk 7 V <br /> Conkacto►—a—u kt F7 _ Address 5-ch—o— Liconse No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service Hell C} <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER ❑ l4onttoriita Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SltWER LINtS DISPOSAL PLD. PROP. LiNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE tYPE OF WELL PROBLEM AREA CONSTfiUCtION SPECIEICA?IONS <br /> 0 Industrial 0 Opera Bottom ❑ Manteti DiA. of We11 Excavation Die, of Wall Casing <br /> f i Domattte/Prlvela ❑ Grsvfd Pick ❑ Tfacy Typo of Casing_ Specifications <br /> I'1 Plrblk I 1 OIh4f fl Delta Depth of Grout Seal Type of Grout �. <br /> i ! Irripetlon _Approx. Depth I I Eistem Surface Saul Iribtalidd by <br /> Repair Work Done Ll Type of Pump H.P. Stets Work Done <br /> Well Destruction ❑ Wall Diarrlator Sealing Material A Depth <br /> Depth tiller Material ii Depth <br /> 4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONDESTRUCTION I I INo septic system permiltbd if public sewer is <br /> available within 200 lest.} <br /> InatsMstiori wait Parva: ftesldOhc6 X Commercial_ Othe, <br /> Number of Wing unki.- Number of b4droom! __m` �A [' <br /> Character of eel to a depth of 3 reel. 6X15 <br /> - Water table depth tw 44#0^ <br /> j SEPTIC TANK. 0 Typa/Mfo Z,t Capacity No. Compartmanti <br /> PKd. TpEAtMENt PLT.0Wthod of Dieposai d1 B <br /> Disttlnca to nairest: WeilEra 4t►�Fobndallon_ r+P Y Ploperfy LIAO . A--f- i <br /> Lt ACHINt3 L E No. I Length 61646 Toidl length/else <br /> FILTER BED 0 Diitanee to nair4Ot: Wall i,Fb r n�a Firopeity Lima .� <br /> SEEPAGE Pits I i fiapth 14-14': tire dumber <br /> SUMPS X Distinct to ""hest: Wolf o ndallori Property Line <br /> DISPOSAL PONDS O <br /> 1 hereby certify that 11160 014pared this application and that the work will be dons In accordance with San Joiquin county ordinances, btete laws, and <br /> rutet and reaulatlont of the San Joaquiri County <br /> Nome owner or(icsnled paint'!iignoluia c6r1014e Ih4 following: "I certify thAt In thA performance of the work for which this permit is issued, 1 shell not <br /> employ any person ih Ouch mahner tin to becomi Wblect to workman'!Eorn0nablion tbwb of California."Controctot's hiring or bub-contracting signature <br /> eortifies the followin#:"I certify that in the parforrhince df the work for*hich this permit i1 Ibbued, i bhell Irnploy pdreons subject to workman's compbnes- <br /> Non tawe of California." <br /> The applieanl fnuat aM for 0 requir In c ono omplet4 drawing bn reverie bide. <br /> Signed AQ Tltli; ZurllLr— Q� <br /> Date. <br /> FOR VEPAgTMftNt USE ONLY <br /> Applkation Act4ptsd byloot/ <br /> ria <br /> Pit a d►out InllpOctbn by Data yinil Inapeetion by Oata <br /> Additional Commants: <br /> Applicant - Return til copies to: 696 Jotguin County public Ifeaith Sorbicbd <br /> environmental Retith Permit/Service$ <br /> 445 N Salt Joaquin, P O Boa IiOo9, Stkn, OA 95201 <br /> FEE A1ylp NT DUE AMOUNT REMITTEDCeK JV <br /> INFO RECEIVED by OAT PERMIT'NO, <br /> -61 <br /> ` N <br /> H 14-20 <br /> l' <br />