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APPLICATION FOR PERMIT <br /> SAN JG JIN COMTY PtJ8LIC HEALTH SEF""n,-Bs <br /> `ENVIRONMMTAL HEALTH DIVISION'--, <br /> Iy 0 BOX 2009i STOC$TON/ CA 95201 <br /> (209) 468"iW <br /> (Complete in Triplicate) <br /> AyPlication is hlr/bfrttttda to Ota Joflquin County for A permit to cor+struct and/or install the work herein described. This <br /> application to *Ade in compliance vith Ban Joaquin Cbuntr Ordinance No. 544 and 1862 and the Rules and Regulation& of San <br /> J09016 COMO Publid Health Sdrviree. <br /> )eJob AddfHe -- 10a _CAIr-�w �Aj u% City �QD1 Lot size/Acreage <br /> •, Owner'I Nana- OUAIIESQM G.97-, rWEiGiiT Address t' _ ., .,, Phone <br /> �.e C�oF,�C <br /> ConTra f � 1 <br /> et0 Address � f('clnst! No. S-633CDs`Phone / 2 <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION ❑ Out of Service Well ❑ <br /> --PUMPANSTALLATION ❑ -'-SYSTPM-REPAIRT0 ~° OTHER- Mortitoring Well_ <br /> . //�• ��1���� SOD � <br /> DISTANCE tt}•-NEARESt; SEPTIC TANK �_. SEWER LINES (I�II'uewi 11 DISPOSAL FLD. N PROP.ZfNEA� <br /> tOUNDATION --UZ— AGRICULTURE WELL _&L OTHER WELL PITS/SUMPS ,..—JI4-- <br /> I <br /> INTENDED U5E TYPE DF WELL, PROSLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial b Op/h armor ❑ Mentees Die. of Well Excavation - Did. of Well Casing <br /> U DoMa/lie/06vlte C dove! Pltk L1 Tracy type of Casing.__ 1-J4_ Speciticslions <br /> d Pub!!e M 01het ndip-'6vj O Delta Depth of Grout Seal 4012:O!14 1.2 0 Type of Grout CaLl <br /> ❑ Irrigation Apptdit. Depth ❑ Clown Surlice Slut lilnstatied by 12011LEfft L--d fcqtC <br /> Repair Work bona U TyrA of PrimpH.P. I Stall Work Dona <br /> well Da1ltuttloh ❑ Will Dlamllet _�,_ 84baling Material tr Depth <br /> Depth till6r Rit4riaf 1I I Mpth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/AOOITION Cl DESTRUCTION CJ INo septic system permitted if public hewer is <br /> available within 200 feet.! <br /> InallAltlon Vtfll bFv � ' <br /> Aumb4r of Who }.rJr .iqN i 'r�-+� ��.y( y t s.}.} <br /> Chltacidt of flblf is l ` ►''i1-41+1 l+fir , ! l■ .�G 4 i{• [ ■ 1 ANK L V <br /> SEPTIC TANK ,, 1 �3',1R10tllr! ..�,orlfE�f� llAlkhfd pip- #:.:/,7EdV� iEtic 1 tjoULtvAaOV v4E$f 9At lAili irto.cA 9s6t <br /> PKO. thIATMENt PC' <br /> LEAC141NO LINt . <br /> F1LtEf1 U0 <br /> SEEPAGE Plt$ 7Nbh <br /> SUMPS ' • <br /> D15POSAl PONDS.. <br /> I hlrlby tlrtify Ihlt f kit''. ,' ws, and <br /> rulfl &Ad flOUl111811 fi <br /> Horne awFiif bf flelMla shell not <br /> tmoloy lily lAtltih Iii 1 signature <br /> C611001 14 fol180N1Rg: mpenss- <br /> tion llwl of C411161Rll.' Y�' 't�'.�+'►t . <br /> The oppkliit mUi dill 101 aN t ult ! r;lk6nil. Complbla drawlnp on t6veflM lidd. <br /> Slgr~aTlile: Date: <br /> 2 <br /> FOR DEfIAllfMENt USE ONLY <br /> Appllcatlori AetdoW by ,,. Dale Area <br /> Pit of afoul lnlp/ellon by Dltl Final Inspection by Date <br /> Additional Commlhtl: <br /> Applicant - Ratu t all dorial,to$ SAN JOAQUIO'COUNTY POLIO !1>tALrH ssl#vicEs <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICER <br /> 445 H SAN JOAQUIN, P 0 BOX 7!008, ISTUCKTON, CA 88201 <br /> FEE 9mo <br /> UM7�l7UE -AM.QUNEMI_TT:ED =_.K a _�.RECEIV.E-D;.BY =T,,.DA7E�--., -- <br /> trrFO- CASH...- _ <br />• Ett771IMEv.+issr ,W QL� <br /> i <br />