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b <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -,D <br /> ENVIRONMMTAL HEALTi1 DIVISION <br /> 445 N SAN JOAQUIN, PRONE (209)468-3420 <br /> P 4 BOX 2009, STOCIT+ON, CA 95201 <br /> T T'ERMxT E%IPIRES l YEAR -Q DATE 1991 <br /> (complete in Triplioat0) <br /> Application ie hereby made to 49En JoaquiA COunty for a Permits to eonatruet end/or inatell the work herein ddacribed. Th1s <br /> pno of Elanapplication is Made Sn coViiance with Salt Joaquin County Ordinance Ho, 549 and 1662 and the Rules and Aegulati <br /> Joaquin County Public Health services. <br /> Gity,e Lot Size/Acreage <br /> Job Address <br /> Owner'o Neme <br /> hone <br /> Contractor ildress _ t' h0. �a —P <br /> TYPE Of WELL/PUMP: NEW WELL . WELL REPL EMENT fl DESTRUCTION Lf or Service 1te11 Cl <br /> PUMA INSTALLATION 0 SYSTEM REPAIR Ll OTHER ❑ <br /> Monitoring Well C7 <br /> DISTANCE 70 NEA8657: SEPTIC TANKSEWER LINES ^—p DISPOSAL FLDt� ROP. LINE <br /> FOUNDATION — AGRICULTURE WELL f OTHER WELL ,= PITSISUMPS <br /> INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATION$ <br /> indu91ri9� ❑ Open Bottom ❑ ftianteca Die. of Well Excevadon Ola. of Well Ceel <br /> CI Dome911c/Prt11valerevel Peck �j�7.v�r�y Typo of Casing� r Specificationsr <br /> l'1 Public Q�f I:1 Oraye I t {a Depth of Grout Sea1� Typo of Grou <br /> I I itrigatr n / Approx, Depth I I Easton Surface Saul Installed by - <br /> Repair Work Done Type of Pump H.P.--- State Work Done <br /> Yt'ei!DesltuCtiOn Q Well Diameter ., ---- <br /> Seeding Material i Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRrADDITION I I DESTRUCTION I I INO septic syifem permined II public sewer is <br /> ayallabla within 200(691.1 <br /> Installation kfl terve: Residence Commercial- Ot110r <br /> Number of living units: Number of bedrooms r <br /> Chatecter of gall to a depth of 3 feet: Water t6b{e depth <br /> 6EPTIC TANK 0 Type'/Mfg — — Copocity No, Compartments Y <br /> PKG.TREATMENT PLT, 0 Method oI Diapooal <br /> Distance to "Brest: Well foundation Property Line <br /> h <br /> LEACHING LINE Cl No. b Length of lines Toral length/sine <br /> FILTER BED n Distance to nearest; Well Founoation Proporty Lino <br /> SEEPAGE PITS 11 Deplh ,—_—Slav__ Number ----- <br /> $UMPS l I violent& to nearest: Well -- - Foundatlon Property Line <br /> DISPOSAL POND$ 0 <br /> I hereby Certify that I have.prepared this applicadOn jDnd that the work will be done in accordanco with San Joaquin county ordinances, Mate laws, and <br /> rules and regulations of the San Jo6Quin County <br /> Homo owner or licensed agent's signature centiles the following; "I certify that In the pallormence of the work tot which this permit is issued, I shell hot <br /> employ any person In such manner et:to become subject to workman's compensation laws of California," Contractor's hiring or sub GontraCunQ signarura <br /> conifiso iha rotfowinq:"I certify that in tho performance of the word for vvfiIv6 this permit is IPi4ad,1 Chnil emptoy persons subject to workman's compens'), <br /> tion lewd of Callfornl®." <br /> Tho apptic m It 11 r all reclui Inapectlons. Complete drawing on rev a side. � <br /> signed <br /> Titla: Ef <br /> X � .... <br /> r01R DEPARTMENT USE ONLY <br /> A pate A <br /> Application Accepted by t to,, �y <br /> Pit or Grout Inspaetioh by ? t �" ata — Final Inapacllon by pet® <br /> Addiilonol Commante; <br /> Applicant - Return all popiee to: San JoRuuia County Public lffaalth Service® <br /> $nvironmsnta2 Health Perrott/Oorvicee <br /> �/J rWr 996 tl Ban Joaquin, p 0 box 2000, Stkn, OA 95201 <br /> J f1`j FEL I AMOUNT DUAMO NT REMITTEDK RECEIVED P- D TE Get/ <br /> IH90 <br />