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-�` APPLICATION FOR PERMIT <br /> SHAH JOAQUIN COM?",y PDBLI C SSALTE S1 �D <br /> $NV I ROMCWTAL EEALTH D I V I S G 4+ <br /> 445 N SAN JOAQUIN, PHONE (209)4 8= -_. . <br /> P 0 BOX 2009, S7DCX7W, CA 9 F rr # _ <br /> 1 T TZL h <br /> (Complete it TrIPlicate) — <br /> APP11t a iod is %AeDI se ce t0 rue Joaquin Gotsaty for s Peratit to construct and/or iw%All the work hereta described <br /> OLQu b COC if Public <br /> 1a Ccjtt beryance cgs.W-ju J3ao Joaquin County OrdiAaM4t 110 5L9 and 1662 and the Rules gad � Zllig <br /> Joaquin County PuD:1e eealtfs grrr1ess. sulstioaa of San <br /> Job Acid,'" �r ter/ r ,,c �.✓ [. c(*�.�. <br /> City.1 Qk'Tr k Int 31st/Acrease 4,� Q (� <br /> rno Cl f Lis/+ G`f t .at f s A <br /> Owrtert Nay Z� Address sZ 1G a,4,crwo i[a.t�.-th .r'wt, r�tc►�Crc v�df�f1' <br /> �.,._. Phens <br /> eontractoc ,1s �sro/cr^.�liG1,� �e.hll acts ? S r4 K (70�ti'SI -9�I-3"- Lttensc No CS'I�az E7 C Phone" <br /> TYPE DF WELLlPUMP NEW WELL O WELL REPLACEMENT Ll DESTRUCTION zk 7 of lser+rlce weu D <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR �} OTHER ❑ riooitonZ Yel-1 <br /> DISTANCE TO NEAREST SEPTIC TANK , SEINER LINES _ CO-,Cr <br /> DISPOSAL FLD _ PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom ❑ Manteca <br /> — _ <br /> ❑ Graysf Pack <br /> Dia. of Wall Excavation Dia of Wan Casing <br /> naon»suclPrtvst• <br /> ❑ Tracy <br /> VI Publ,t Type of Caging�"Dtt.er �1•++. is'T n Delta Sf}eul,Gsudns— . <br /> I f irr,patron `S Depth of Grout Sgs! Type of Grow <br /> Approt Depth I I Eastern Surib" Sail installed by <br /> Repair Work Done D Type of Pump <br /> H P State Work Dora Petr,r r� a,r� •t Q �•p f <br /> well Desuumoon Won Dwreter � � <br /> -r-7- � g riaLerla., i Death <br /> Depth S-G . <br /> tiller Material i Depth r <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I 1 REPAIR/ADDITION f I DESTRUCTJON I 1 IND tept,c system perrrunaG d puW,c sewer u <br /> oul"I'alin evadable within 200 lost ) <br /> Cdn+rr+erc,al_ Other <br /> Nurrtbsr of kvwV units � Number of bedroom, <br /> Chsrauer of a" to A depth of 3 leer <br /> SEPTIC TAMCWater table depth <br /> fl Typo/Mlq Capacrty NO n ` }-- <br /> PKG TREATMENT PLT ❑ � V <br /> Met <br /> Dwaine to nearest Well Four,da[,dn Proo+rsy <br /> LEACHING LINE ❑ No 8 Length of l►net <br /> FILTER SED Total Ion In/ <br /> ❑ earners to naaresi Weil <br /> Foundation Pr !V �7 SEEPAGE PITS TaeOth S,z• Number SUMPS LI a,atanca tri r+++►sat walkDISPOSAL PONDS 0 FondeProperty Line �+ <br /> I hereby Certify that I he" prepared Inn aPSWCauOn and that tM wprK will be S <br /> re"A and rf�at.one of the Sen JOepu1n 1;�tta none 'n accordance with San JoaQotn county ordrnancas stat* laws and <br /> hlorrr Dwryr M bC,erraep L7" <br /> spent a tt.¢nature c'muf n the lobowrnC I Cart"that m the p*rlorrnanca of the work lot wh,Ch thn pernw[ a naua4 I shalt not <br /> frk <br /> *orb K't dao^ �++a+�rna,+ner as u a'G0r*" ++,per to r+rortnnan t aa^,per>s+t+on Ie.vs of California Contractor t fnrwtg or auatmnuacunp apnetu,* <br /> tyft'IM the 1paOwtrV I C;*-y that in tna parlors WIC-of the work lot wls,Gh tlrs permit,t,a.urlr I S U• <br /> bon laws of Caldotryt` mP+oy P*raono aubleet tD workman a tprttpenai <br /> �* ��t[ "PAW tit lox all r*QureE <br /> /l�! ^ + Ca++tpi+t* draww►p on reverm sada <br /> signed ,/ �� TrtwQ �J <br /> 1 Date ��� / <br /> � J <br /> FOR DEPARTMENT USE ONLY I � <br /> Al7oJ,e.ttor, Aaaoea0 br G / 2 � <br /> Dais Ara. 35. 02- <br /> Ort of Grout lneipati,pn pY <br /> Dau Final Iruoecvan by <br /> Conrn..,u <br /> M�t Date <br /> ��S�Y.J G[ m� <br /> Ap>gllcwat - Hetttrn ill Copley to SLM .IoaQult County Public Be;1Lh Servicee <br /> Soaironm"L&I JteaithPermiil5erVlcaa <br /> i{S h San 3ot►�uin, p D Box 20()9 .9tka, CA 95201 <br /> FEE f a <br /> [MFp AMOVNT DUE I� AgepUNTf�REMr'7ED CK GAS►f RFCFNEA f!Y � DATE .FItl.1lT WD <br /> `�IRZ:V tr�gt- 1i✓ l:_/Of I � �f Jr I ��T"iC'J` � � + i <br />