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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY Pjj11BBLIC HEALTH SERVICES <br /> _NVIRONMENTAL HEALTH DIVISION I <br /> _P OBOE 2009,' STd=T0N, CA 95201 <br /> (209) 488-3447 <br /> pggmlT XXpTRHQ 1 YEAR FROM DATR ISSUE <br /> (Complete in Triplicate) <br /> Application to hereby rAa•to ass Joa4uin County tee a perch to construct and/or Install the work benne described. This <br /> spplicatlen Is cad• In COVIlanes with Ssp Josgltin County Ordinance No. 549 rind 1562 end Us Rules and IIINUTALicn1 of tan <br /> Joaquis County Public SMltb "Ie•i. OFg <br /> Joe Address Cay Lot,Stal/ACrosee lif <br /> Tt Own. • NMM 17101M 'fie a_ / Ayee�r.a �� ��J <br /> • Contracts AOtlre4 r� �� I�a�Uceme No. 2.'373 Phone`jy2L1_ <br /> TY E F WELL/PUMP: N WELL O / WELL REPLACEMENT 0 DESTRUCTION 0 Out Of,- n .11 <br /> t' PUMP INSTALLATION @' SYSTEM REPAIR 0 OTHER 0 Iaelterirle well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.- PROP.LINE g <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑� /IrM�uatrw ❑Open B"w 0 Manteca Dia.cf Wens Excavation ole.of Wtll Casing <br /> W'DOm4tK/►mm 0 Gravel Peck 0 T4cy TYoo of Casing Speclficetiee i <br /> 0 Pub& I71 Other O Dalte Depth of Grout Seel Type Of Oro 1 <br /> patron _AMON. Depth ❑ .stem -Sueia1.1 <br /> law Best Inaw by <br /> Rapor Work Done U Type of Pump , t <br /> H.P.�/io State Work Dale <br /> well Destruction 0 WN ownanr Sealing Material a Depth <br /> Depth. Piller iaNrtal E Depth <br /> r TYPE OF SEPTIC WORK: NEW INSTALUTION 0 REPAIR/ADDITION M DESTRUCTION❑ INo sspw syetern permined N public arWo,a <br /> agilable within MO(nst.) <br /> { Inste4tan'NMI 4M: ftelaence_ CpNMrcial_ Other <br /> s Numbs of wN+p unite:_ Number of bad e <br /> ctw o of'.snA to a deem OI 3I=, Water table doom <br /> SEPTIC TANK. O Typa1Mfq 'Capacity NO.Comwnmante <br /> PKG.TREATMENT PLT.Ll / Method of OipuN g <br /> DManu to mamt: W Foundation�,._ Property Line <br /> f <br /> 'ACHING LINE 0 No.L Length of linea - Total length/size {p� <br /> ' PP_TER BED i 13Oatar+ee to nearest: en Foundation I Property Lina i <br /> "T_• / <br /> SEEPAGE PITS : 11'i Depth S've_ Numbet <br /> e SUMPS LI fflp to n4r4. Wss uMof n Propeny Lbs i <br /> e <br /> DISPOSAL PONDS 10---' -' Z <br /> I MrebY testify thet I hM Repand rhb application and than the work will he annI,in aecordonee with San'Joapuln county aldM+arrtel,a4b nates.este <br /> Nle,and regulations Of the Sen Jcmuin County �/1 <br /> Moine ovine Or,4 nal epnatu:e 4mlioe the 1 w+ng:"I coMfy the In the performance of the walk IV which this permit is issued,111116111 rot <br /> empbY eltY N wt tressle tee to Oma w I o Workman i corn"M41i0n IOW.OI Gafalrvs.'•COMOCtOfe luring al wDCOnlrNtaQ alpNtwN <br /> cleanse t OEowinp:"I that int or f IM wort for wnreh I tri mit ie YeWd.I ahall arnpIcV peralr.I Subject to workrnwrlY COMON14' I <br /> tbn of CYN r <br /> The• •M .C pen erewing <br /> _S.C'� <br /> SipnsO TIIIe: '� _ Dat•; 4- 30-4/ t <br /> F:.7 DEPARTMENT VEE ONLY Z•IZ f <br /> ApYKat,n Accepted tryl //� Date Ates <br /> PN or Grout Inspection by Dote Final IMpecOon / <br /> AdOebnY Conurrnn:T =�AS !iP is.a-. �Z✓✓:vi r�rT//M ll.P�Il ''ff�� <br /> Applicant - hetucnta31 bepiee to: SAN JOAQUIN COUNTY PUBLIC NNALTA BERVICNS IAA <br /> ENVIROIeiTMAL HEALTH DIVISION PMIT/SRRVICNS hLVt;. <br /> I 443 N SAN JOAWIN. P 0 e02 2009, ETIKINTOI. CA 00201 +�yy <br /> FEE AMOIINt DUE wNAUNT REMITTED I ae"NED By DATE FERMIT'NO, K' <br /> INFO CASH / <br /> :.. n / Y <br /> .a«tss•IREw....0 s.OD `�I Y <br /> e« a <br />