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t APPLICATION rOR VEHMIT T <br /> SAV JOAQUIN COUNTY PUBLIC ELEALTH SERVICES <br /> ENVIRONUIWTAL XUALTH DIVISION <br /> P O BO% 2009 , STocKTQN, CA 95201 <br /> (209) 48$-3447 <br /> EXPIRES 1 . Y <br /> (Complete in Triplicate) <br /> 1 Applicattoo 1s hsrcby made to Sad Joaquin County !or a Derait to const-uct and/or Irstau the vert bertln described. 7KIa <br /> applitattoo 1t rade to ccoplianca vitb Sao Joaquin CouAty Ordinance Ito. 5L9 a.n.: 1062 " tCe Rules " AepiUtlora or ua <br /> Joagtlla County FLbll_c/ittalt5 84ry:Cee. <br /> Job Addis" -ray M9ZR- city 9tce/A:re&&e <br /> ILlD - Andress ! J~. PTor4DAWU T< fJO+nt <br /> Qwn4r't Name - - 75tC1 <br /> r'Onlr7C10r . ;.Q/I��fi (1TIt1AL ' AdGress 11275 sirnn% ('ael)C. sCctmst HO.0 7"�077 �f 6 ZsZ 74s� <br /> TYPE OF WELL/P�UtiP- NEW WELL O WELL REPLACEMENT ❑ OESTRUCTION ❑ Out of ServIC• dell ❑ <br /> SYSTEM REPAIR L-1 OTHER C„ A4GtrStorl^$Ytu <br /> PUMP IN5TALi.ATtOH ❑ - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PAOF. LINE <br /> FOUNDATION ��- AGRICULTUAE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PA081CM AREA CONSTRUCTION SPECIFICATIONS <br /> L' Industrial ❑ Op4n Bottom O dente" Dia of W+u ExClv,114A Du, of WON CBssng <br /> 03metl clPrrvat+ ❑ GrsYr+ P+c:r C7 Tracy Type of C4s+ng Pye Speelkaliont <br /> QAj .- <br /> 0 Prrbk 1:1 Other ❑ Dert4 Oeplh of Grove Seat Typo 4f Grout <br /> Ci Imeatron - r Aprroa. 000:h ❑ Eastern Surface Seal Installed by <br /> Rvoay Wort Done D -Tye% of Pump H.P, State Work Done <br /> WON DestrLrction ` wag Oiarrra!arSeallnd liaterla: i Dtgtb <br /> Depth f tiller ?ia .erlal i Dopth <br /> TYPE OF SEPTiC WOAX. NEW INSTALLATION 17 REPAIArADDITION C1 DESTRUCTION J lNo soloolre system permrrtad i! arr'it.c saws u <br /> avallab4 valhrn 200 fe41.1 <br /> natsllation w;R s4rw: R4sid•nee _ COrrv++rei+t — Otri4f <br /> VWI4uber of Iiving units: Number of bodroorns <br /> Gm+4rUtee of Sol to a depth of 3 feet: Water table dvoth <br /> SEPTIC TANK 11 1y4e/M11 t:aF►acrty No. Cornpertrnents <br /> PKG, TREATMENT PLT. C1 Method of Onpoaaf -_—� <br /> D4tanu to a varett: Won Foundation Properry Lin. <br /> LEACHING LINE Ll No. b Length of lines Total length/tilt! <br /> FILTER DED fn Dutancs fq nearest: Wan Fovr+4atior+ Proogny Line <br /> SEEPAGE PITS 11 Depth Site Hvmber <br /> SUMPS LI Distar" to Merest: Watt four►d+twn Property Line <br /> DISPOSAL PONDS ❑ <br /> Mreby Cen,fy that I haeme prsoared this application 04 !h4l Ih4 work wit! be dome in accor8snce with Sart Joaquin county ord'nancss. 3111014Y4. And <br /> uit, <br /> and r►gvlalions of the San Joagvin County <br /> oma Own4r or licensed +gent's kt%aturs cond-as the 10IIOw.ng. "I Camey Thal In the periprn,ancv of this Wort for wnreh this perrmt N issued, I stiah not <br /> 4rnploy any parson in wch mu+r4r as to become wbrtCt to w0r►m3n't comoer'aalron taws of California.'- Co.ntractof's hiring Or svaconuacling eignatura <br /> artifiea the 107lowing: -I certify that in tn4 periorn,ancs of the work for which this pormit is is.aued. I trail ernploy p4Fscns Svb.04T 10 v*Vkrnin's C0M-P4nJA- <br /> ron tams of Uilotru.- <br /> ha APP14ant aeitl ull.rar/r) requ{hr!inttr;t+or.:. Com; ete drawing on ttverse side. <br /> octad X ..,-- TaLis. --- Date: <br /> 'TOR DEPARTMENT USE ONLY <br /> Application Acc401e4 DY - w- - Date Area <br /> t or Orevt Inap.Cfion by Date Fina! Inspection by Data <br /> nt! Cornrnants: - <br /> lit+�a; - .1vULM all copies to: SAX JOAQUIN COUNTY PUBLIC HYA,LTH SY.RVICIS <br /> ENVIRONWENrAL 11EALTU DIVISION PLUIT/31AVICES <br /> 445 X SAiI JOAQUIN, P 0 BCtif 2009, WrIXXT04, CA P5201 <br /> SLE AVOVr6.T OU( AMOVW aEu TTID lt[C[rv(D 4Y Dar[ /E�M+T,HO. <br /> Iwo GaSM <br /> JACv <br /> . •rix •. . .... 1 _ <br />