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APPLICATION FOR P$BIiIIT <br /> SAN JOAQIIIN COdMPLIC <br /> SNj 3 <br /> MVI HSALTS <br /> 445 N 30N JOAQ[TIN, PHOl�B ( —8420 <br /> P O BOX- 2000, S, <br /> RMIT <br /> (Complete in Tripli <br /> AMUcstioa is bMbW a"& to'Sea dosquia Cmtaty for a perait to construe <br /> sglRliestles is sane 'a ccmillsw* xlth Bea Joaqula County Ordiaaace Bo. SLe <br /> JosAttia Couatr Public Nealth Services. <br /> Job Address �� City 4. Lot Size/Acreage <br /> Owner's �ri<I" .1 ea,kdd on V-1)� `.Q*�rso_ RA*UM. Jo6r►.&Ht PhorM 0o era—?69j;' <br /> T' <br /> Awl <br /> Contrular �S ass P8 LicenseNo�����?.� Sim 2 <br /> TYPE OF /PUMP: NEW WELL K WELL REPLACEMENT .. DESTRUCTION ❑ Out or fervice Nall <br /> PUMP-04TALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Moaitorlag tfall ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AORldiXTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PIfMEM AREA CONST1114CTION SPECINCAT10NS A, <br /> ❑ Induettfal O OP+n bottom ❑ Mintrca Dia. of Well Excavation ' Dia. of WON cnhv 'Z <br /> ❑Grow Pack ❑ Trocy Type of S 4e fc. <br /> {l DNa Cps1p � SpecrNcatrona <br /> p11(twl' Depth of Groat Sow � _--' -- TYPO of <br /> I 1 MtiMation AJDhkf�Vft. 0610111 1 1 Exam Surface Seal instaud by / J6 <br /> Repair Wink DOM ❑ Typo of Pump H.P._._ _ Sts"Work Done - ? . <br /> Wed Destfliction O Wish Diameter �__ Ses.11"-tlaterial A ftth ^j d, % f 1 <br /> l.le'�+►t <br /> DqpIh ller Material i Depth Se41 food"" <br /> Tim Of : NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUC ION 1 I INo s Om permitted if public sewer ie <br /> 4001111114100 VA rds <br /> ca : Ibefd Concur Other p �E00 fMt.i <br /> Nwrtber a Nunrhu of b.droorns RECEIVED -� <br /> Ch MWW 01.40 to a depth of S feet: n C G 7 yIAU �,► <br /> SEPTIC TANK. ❑ Tyne/Mfg Cam ityk � <br /> PKG. TkATN MfT PLT.❑ SAN�'Q <br /> Distance to enarsrt: WON Foundation <br /> pUlea Ljr HE <br /> LEACHOW Ulf* 0 No.i Lenptli of Mn Total kngth/size <br /> FILTER WD D Distance to neemt: Well Foundation Property Line <br /> SWAM PIPS I I Depth Site Number �+ <br /> SUMPS LI Distance to ntlarso=- WON.,_._ Foundation ProWly Line <br /> D"WKG t PONDS O <br /> I hereby owlify that I have prepsred this application and that the work vaN be done In accordance vitt+San Joaghin county ordinances.sato Iawe, end <br /> n/sO artd 006tintts of the Sen Joaquin COwtaty <br /> NOW ONVOW or Non 18 agent's iiarahne oatNSes tha fok wing: 111 cw*y shot in the perfonwkwe of the work for.which this permit is iesled. I dW not <br /> earpfoy Day passu>n such mender as to bacans su4jact to woricrtlen'6 emop nation laws of CaWornis."Contraetoeo hirft or PA"onvvc ft alippo m <br /> Dundas the faSewhlp:''i emit#M in the pvWmencs of the work for which this permit is issued,I shah employ persona subject to workman's canwenOe <br /> tion laws at COMamb." <br /> The ap ke0 to for al required kwplctiona. Cmaplae dnwkV on reverse side. p �+ <br /> $Wad THM' _ SSS �l10 9 ft <br /> Den: <br /> 41 <br /> FOR DEPARTMENT USE ONLY q <br /> APIA Accepled by � � Data I� � !3 Ana oe1� OIL. <br /> Pit or Gram htapecdon try Date Inapecdon by_ _•„•�.Diu 4 <br /> ]P <br /> Additional Commerra: <br /> Applicast. -•R*turn all copies to: San Joagvia County Public *alth services <br /> X110rosr estal Beelsth Pewitfaervices <br /> 445 X San Joaquis, p O Box 9009, Bt11a, ©A 98201 <br /> A t�' AMOUNT DUE AMOUNT flEMITTEO C MCVM MY DATE PEflti11T`NO <br />