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M APPLICATION FOS P R.W I T ' SAN JOAQUIN COUNTY PUBLIC M7AI.TH SERVICES M VIRONYENTAL HEALTH DIVISION 445 N SAN ,IOAQUIN, P$ONZ (209)468-3420 P O BOX 2009 , ST0C3:TcX, CA 95201 D ERN D S UZD (Complete in Tr=p:L+cote) App.*cation 'a hereby made to S� Joaquin County ror a pera.'t :o Ce¢at-�c_ and/or ata l' t.:e vork herein dascrihed. nix 'ill- County a stipll in it haste Cath 3e¢ TaaQui2 County Ord-"asci So. 5K9 And :862 and the Rules and 3eguiAtioas of San sequin County AshL'c 8e�,:.b 3err-tces. Joa Address Cay rti L+. I,ot 51ye/Ac-segs Amer s Name U^C1 CAddress 5 +•+e. yJa '� �s �� 4 Phone Contractor L�<••,• �••.,G t]r 11 � '�, Tn� Address A&- k, e-A rfYO z,' C�-s?� •7 / Lrceose fio Z Phone\�/r� 37-2 - Z9ect 'PE OF WELL/PUMP NEW WELL WELL REPLAcEmENr c-, DESTRUCTION 0 Out o1 Serylce Yel ❑ PUMP INS T ALLATION ❑ SYSTEM! REPAIR C OTHER ❑ Xcriltoring Bell DISTANCE TO NEAAE57 SE-TIC TANK - SEWER LINES - -1.) DISPOSAL FLO PROP LINE /0 FOUNCAT;ON !L5 �r AGRICULTURE WELL - OTHER WELL SQ 4- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATTONS C, Indusmal ❑ Omen Battorn ❑ ManteW Da of Will Excavation_ �•'�I+ts Oa of Well Csernq r^� Domestic/Private 14 Gravel Pack ;Z Tracy Type of Casing FVC- Specrricaoll C 4S7� °^r6. clams I Public n Other n Delta i I Irr tion Depth at Grout Seal +- '-C �W � AOpra= Depth ;I Eastern Surface Seal Installed by Type of �� Qepa+r Work Done L3 Type of Pump H P State Work Done /ell Dastrvct,on Q Wer Ownetar _ Sea.ilttg 7tiaterial i 3epth Depth Filler liatertal i Depth TYPE OF SEPTIC WORK NEW INSTALLATION I i REPAIR/ADDITION I ! DESTRUCTION E I INo septic system pernuttad al �\1 pubfrc trurer ra Installation will carve Rasrdanca , Cammerctal_ Other avulable wvethrn.700 feet.! NunebW of Wiling units Nurnbw of bedrooms C?wacsar of sod to a depth of 3 feet: avatar table depth v. EPT1C TANK ❑ Type/MfQ Catsacrtr�` NO Car*+oarttntrrtts ,jxG TREATMENT KT ❑ Method of Deposal Orctsnce to nearest Well Foundation Property Line LACHING LIME 0 No. b Langth of Knee Total length/sue FILTER 880 ❑ Drstarxa to newest. Well Foundation __� propleny Lane iEEPAG.E PITS 11 Depot Sria Number SUMPS L.1 Untanc.e to nawast Way Foundation DISPOSAL PONDS ❑ PfOamr txta---- i heretry certify that I haw prepared trust a17pLcatsorr end that tt+e esprit wvrd be dons n accardanca writ! San J vkia and rpulategrra of the San Joagann CQUAtp aaqu,n Carnia tsrdrnancas, stats lava and Hama owner or t canned pent a argnatura Certifies the falbwrnQ 'i Cal that m the performance of rho worts for which this Pal is sswd, I"I not antploy any person in all manner as tp become subpci to workman a compensation taws of Caldarrna Contrac:o�s hrrtrtg or sub-Contracting signature earttrres the fotiowrr�. T csrofy that in the padon Wil of the wort for which thin permit a�aaued.I shall r tion !arra of Cairfornis " rTtploy persons twbpct to workman a carrtpen=.f- The applicant must coy for aM requred in Complaa drawing on revarsa side Signed v�• l..-�� rtes yrs • Data- Acca ApplrFOR DEPARTMENT LlSF ONLY utign ptad by /�" Date Arses �7 Ph or Grout Inspeeaon by "`-`�'` S Data Final Inapl by Dau Addnional Corterrrants }�- Applicant - Return all Copies to San Joaquin Count? Public Bellth Services $avironmental Aaaiyl; Permit/Services 443 K San Joaquin, P 0 Boar 2009, 3ttn, CA 95201 i FEE AMOUNT -,uE AMOUNT !lt:AACX a �� INFO r ��7 iTT>;C CASH I RECt INFO dy OA'E PEl1NR lAl Ll'), 444XVV �,a all .a 9