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APPLICATION POR PERMIT
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<br />�e 'S(_c�Pr �5746I c r t i/ SAN JOAQUIN CCSV*TY VbSL 1BHALTH SERVICES �0�%�''` t
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<br />ENVIRONMENTAL ALTH DIVISION
<br />P' o Nit 200 STWKT69;CA 95201
<br />(9094'14992447+ r t:.
<br />vteve - P,y (3A->(6 sstr$D
<br />(Cothplete in Triplicate)
<br />Applicatioa ii hereby made to 8sti`Jbagtt10'1lutitsy' i t' �E-, o.: tidf"t is andtdt'''inrtsll the trotIt hoidid 4ictyibed.' This
<br />application to redo in e*Vliattc: with Sart Jp►quin GouatY,,Ordinance, Nosy +544 and -1669 &A the Rules abd;Hagulations of San
<br />Joaquin County fublla Health;Betwlce
<br />Job Address se/Acre a u",
<br />Owner's Name �r Address Phone
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<br />Contractor dress` icetse No:.�.: phoria • - r•7
<br />TYPE OF WELL/PUMP:, .. NEW WELL ©� , WELL REPLACEMENT 0 DESTRUCTION O Well Ll�
<br />PUMP INSTALLATION O; i � SYETEMREPAIR'O ioRitteritig;well 0.
<br />DISTANCE TO NEAREST: SEPTIC TANK SEWEA; °LINES DISPOSAL PLD. PROPS 6iN }. .
<br />POUNCATIi)N. AGf§tow RE ELL a OTHER WELL`
<br />PITS/91.1
<br />INTENDED USE TYPE OF WELL i PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS t
<br />n industrial ® Open Bottom '; 0 Mantecai Diary f Weil Ekcavatiori t Die., 61 Weil Calling,
<br />U Domestic/ Private 0 Gravel Pack, LJ Tracy . , . , Type of Casing a - , Specifications a
<br />M Public 1:1 Other O Delta i booth of'Gtout Saalt
<br />Type of Grou
<br />Cj Reaair W� Don*, LI Tye Approx" booth , 0 Esiiern 1 SuifEL mi initatheii`t a _, M , ..
<br />of Pump ; ,_ ->. s H. P« Ata a terror, D ' e t t '
<br />Well Destruction O Will Diameter
<br />Seal its watorial,iDot
<br />t 5
<br />TYPE OF SEPTIC WORK: NEW INSTALLATION 17 x REPAIWADDITION-,CL,.4OESIAUCTION. �No sepild ayatel
<br />cava bee withinrrnitted pttbi r ,.
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<br />Installation Will serve: Resident* ornmarclai .; =; Other z:_, �� n � � �d _ � $rN L, il�'r+�r,f1eC
<br />Number of living unite: Number of bedtooms l F' SCO tN {
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<br />Character of sea to a depth of 3 fast: All Water table depth
<br />SEPTIC TANK O Type/MfgCttmpartMehft'
<br />PKG. TREATMENT PLT, Ci t
<br />Method of Diipoaai '
<br />4—
<br />Distance to near(A , :Well i. Foundation �, Property Lina • �� � �i
<br />LEACHING LINE O No. S Lionoth of lutes J i i i w i forst fefigth/�i3e
<br />FILTER BED n Distance to nasteat� u Waif a i°otandation� Property Line
<br />h
<br />SEEPAGE PITS 1 1 Depth Site
<br />Number ;
<br />SUMPS LI Distance to rte�I(rost ;WaH ,a oundatian �. Pr rty Line ) T
<br />4
<br />DISPOSAL PONDS � D i
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<br />hereby csrtifV that i haVe prepared this application and that *401 r�ttnll a dorsa its accordance with Sin Joaquin county ord(nances,atate lows, and
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<br />runts aril ragulaiitlRe t►f tfii Sin JBa�jufh' pounLy � j§
<br />Nome owner or licahaed 000nt's iignalufa cirbfiei, the 11611dwinp )'I cahify fhit,16 the performance of the Work 'for which this permit is issued, f shall not
<br />employ any person qt sutlfe rnemnif is to'1 t:dr�is Object fd iri+brt+r iiit`it t:c� i6ft i.40' L"a1it6." Conti cWi vilho df W6166 ideating signature
<br />s cenifiss the following!: "1 certify that In the P6�iormenca of the ! o flit ich this r�` it Is liauid, I shall i ploli peribns subject to i>iriifkr�en"e c ' nsa
<br />awe of
<br />lion t Ci{ifoiRia." gin. ,.
<br />Theapplicant mus caH fair rad ih tNtha,. Com ' a
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<br />pec pi fe dtaWingron fttfaa side,.
<br />Signed
<br />ItNI. Data
<br />!~CSR iipilq tNllfif`l; U#� CJtYL1r
<br />Application Accepted by , Q "
<br />.,hate , .�
<br />1 . Aide
<br />Pit or Grout 1 tion by Data Final lrispsFioh !iy r Data
<br />Additional Comments'
<br />..
<br />Applir:ant Return all to siee tat OArr J� gtrrx COUNTt �tci3 '
<br />rr w,BlvviRt tM>itdt'AIiAt ALT fSty�S� °P�1fi T/BRRiitL"H�
<br />iib N .8014lA BIN 0 C3 , ; Sofigt f c CA gti'�Ol �
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<br />FEE
<br />AMOUNT DUE ' AMOUNT AEMi " 96 RECEIVED EY `)ATE PERMW NO. {
<br />INTO . -x,. CA H
<br />• EN t324 (REV. i
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