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• APPLICATION FOR PERWIT ������,,y�,E�,. <br /> SAN JOAQUIN COUNTY PUBLIC IIEALTII 'Pn47T\`# �l <br /> ENVIRONMENTAL REALTR DIVISI N1'f��f E <br /> 445 N SAN JOAQUIN, PRO NE (209)4 RRii P I <br /> P O BOR 2009, STOC%TON, CA 9 0�C <br /> pERMIT EXPIRES I YEAR 'P l�A <br /> (Complete in Triplicate) —I <br /> Applicatlp la be[<by aside to San JoaRusn CoddLy for A permlt to construct and/or instill t1.e "'k bareln descelDed. Thu <br /> appliesti°o is cede in coopllmce with Sso Joaquin County Ordlrence Xo. 549 and 1Bba and the Rule- apd ReA'ulaalooe of San <br /> JoaOulo County Public Health Services. 11 <br /> 91VA. Cnv.]LV-�1:�== Lot 5111/AcreaKe <br /> Job AOduas � 0 p ,(o•J / ,r A <br /> Addlefa / •O• p6x.��Z <br /> . ownn'a wne <br /> 3,z4f Fl�srr•/.0 Q•(.Ik2 414.fLf-20;.Z z�zo Pn°n�S.[ B.CZ•afSel <br /> •�v/rt✓ x ... �-C•Address Q ^ � G..!•w.e_1r•1.�_3.._License No._ <br /> _ CoNoclal_ <br /> TYPE Of WELL/PUMP: NEW WELL R WELL REPLACEMENT 171 <br /> DESTRUCTION ❑Out Moniurltg V<]3 <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION G >rta' PROP.LINE r�- <br /> >.Ia r SEWER LINES >� DISPOSAL FLO.__ <br /> DISTANCE TO NEAREST: SEPTIC TANK >('11 OTHER <br /> M'ELL >J'e $/SUMPSr <br /> FOUNDATION 'far AGMCULTUPE WELL O 2 111 <br /> .r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS of Wed Ca �•• <br /> ❑IndusiMl .- ❑Own Bcr O Manleoa Dis.of WNI Esuvnion 1r,[q C <br /> Trac Tvu of G-Inp_'4K Specilicatiors £` 4 <br /> t fl Dareatk/Pr'rvne ❑Gravel Pick ❑ Y /f`• Type a Grout u d'A'r'•fi (t <br /> I't Frolic fA.Olnsr n Delu Depth el Grout SW w <br /> I I bri{E-Ibn �Apprea.Devil 1 baurn Sort..se-1 InLNed M <br /> -jt _ H.R Star.Work o -�_ <br /> - R"Iur Wak Dau ❑ Tvpe of Pump -- Seelig 1laterie1 a Depth <br /> !%{ - WNI Lseatructon ❑ WAIT Dismatn .-- 11 L'er tyterlal + isepth <br /> . .. - Depth <br /> .'. .TYPE Of SEPTIC WORK: NEW INSTALLATION i REPAIR/ADDITION I I OESTRUCT:ON I I ilb wsUN IMO�eatt,d d arblK aaw�I a `r t f j <br /> ' Intsaaeion wiE seam: RaadalKe_ Caarercul_. Other <br /> b <br /> ' <br /> Numbly of W:q uNo: HumDad <br /> r of Drooms _W atn bele depth <br /> y ..DIWKt-a 01 soY w• ki ass of 7 feet: <br /> - No.Compartnrrtta <br /> SEPTIC TANK. ❑ Type/Mlp Capacity- <br /> Method of i YN:__. -'+ - <br /> pKG.TREATMENT PLT.❑ FourW-ton PnofseM Line <br /> Dina"-to nesrerC Well <br /> Total enBtn/une i - <br /> LEACHING UNE -❑ No. E L."m of lire- <br /> e Found~ Pro__Line <br /> £ FILTER SED _. . ❑ DlnrKs to nenut: Wall <br /> p—clnniTrSERVICES <br /> SUMPS p1T5 <br /> f 1- Depth Site Number�-'�.....-rry <br /> ..,�.. SUMPS LI Dina"w w rwrwc WNI_�-_ FourWnion Ploparty l'w 1 .. <br /> DISPOSAL PONDS O - <br /> '.I MUDS L PO IMt I Mw pepard ihiupplKrtgn and that the worts will be done M aE<orGnca with San JnlQVln county aalu"n,Pati ewr.,end II - <br /> .ruW-rd rpul-t"01 tM San JoaOuin Couaty <br /> HMte owner a licensed agnt's-ignatun ce,10mrs tM IONo .nB."I unify Ines in the psdormancs of the work fa weticN tnro eermt'r Laud.I shad"t ,gyp b <br /> ' •. <br /> no"jury MY p-rpn in ayf.D INnw as 10 bKnme Wbfact-t° °rkm-r11 conn"r oalinn bw1 of Dslifaae-Cnntr\ctOf a hafinkl a WD'CM1rKIm0 MOrNEBte 3`L It <br /> Ueif W tM Ip W kn:"1 urilfy that in the paNama"s MIM work for which this pant if esu".1 shall employ Onions subject to work <br /> mN's umpensa- - (C <br /> Horn Well Of C4'M rW," <br /> ..i <br /> The applicant n n W la aha rpuJld is tbns. Compiels drawing <br /> � erlt� <br /> $,n.e c�� ollc <br /> FOR DEPARTMENT USE ONLY <br /> Dae I An <br /> Applies ACCplei DY <br /> i 'Data / 1' ? Final Inapecdpn by 11. .. <br /> I PK de Grout Inn-Kron by - <br /> - AddhionN Carvrentr .- .. <br /> T - Applicant Return all coplee to: 9ani=Co ental°Neat to Pepoblvit/3"lliceaIth vlcee <br /> / �- \ now CA BS]O1 I <br /> Yl J '�(I/t ta6 M An J°aeu tn, P O Boz ]DOB, 9[tn, 1 <br /> F`EO AMOVNT WE AMOUNT KEMRT ED CASH KKEIVEO lV DATE PERMR NO. ��a` <br /> _; GGGssr <br /> Is"AN vat <br /> 'v'r eK us ' <br /> ..-:rte .nC"`�.•M•i`3A"oiv.:-�:' a <br />