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f k co „ k i APPI,[CAT 10.1 � O( A IJ 1 N COUNTY PUBLIC HEALTH SEI1 Y kd°1V[1IOitiT&3ENIAL HEALTH IM13.O.�T ' Th- 5 N JAN .10AQUIN, PHONE (x139)468-1.1 P O i3OX 2009, STOC.I(TOI3, CA 95X1 Pk;ItA9I'I i iPiREC 1 YEA1t FROM DATE I_5SU ` ;� (�'omplete z11 'iriltlicat+:) �+ Application is hereby aade�Lo San :cs;uln Cc,unty far a perml% to construct an=Vor innLnu the work herein i .o � application Is made la compliance frith .^ren d_,nquvi Courty Prd;nance Ifr,. $49 nod 1136-2 and the Sules e,nd Aeby Joaquin County Public Health /Uervicea,_ r Job Address �47��L r,< <_ /.�f� yfr�r,!'� T _.I.vq'S]xe/Acrikge �.+I ' 4`�t�• �G.:— --- .�- /✓. / Owner's Nems��F ;^� --... Add,"i mel �_ _rf�t�r� a.x��... PttOrfr.• f � f Contwcfo, ?!+�+1} -_--adaress 3's?�S' { _- L cense Nc. r4��Lf 3 Phone �� TYPE OF WELLfPUMP. NEVE'WELL X, WILLI. REl'LACEME' T fl DESTRUCTION i;l out, or Service We.1.1 C ;I PUMP INSTALLATION SYSTEM RLPA!H ;, OTHER r Monitoring Well. E1 - OiSTAr,XE TO NEAREST: SEPT$C TANK SI.WER EINES __,_ -. DISPOSAL FLD.' PROP, LINE FOUNDATION _ AGRICL'' RE WELL _ OTHER WELL _ PITSISUMPS , INTENOED USE_ TYPE Or WELL PROBLEM ARE .-,ONSTRuCTiON_SPECIFICATION'G �� l i IrKlustnaf a C3 Open Bottom6'ant0ca Oen of WellEsrava,hpn_ 'Dia.of Wall Casing r ,` ---- IN k YDomestic/Private Cl Gravel Patz, 1.1 Tlacy Tape or Cas,rj; r Specdicaiions Cj V1 Pt,blic fl vthor/ i 1 Oel:a :Death of Gfout S".111 Typeµ Type of • t 1 In,gab -1�on � pptus. Depth 1 I Ea:lofn SuflaCe oval Instaltbd by Repair Work Done 4.0 Type o1 Pump P,e Slate Work Dae:: _ k ,aeelilg Material Iii "Depth 1 Well Destruction i O Will Diameter " Depth— —_- Filler Ma Ler'al L lupth TYPE Of SEPTIC WORK:. NEW INSTALLATION i I sl£PAIRiADDITtON I I DESTRUCTION 1 1 iNo septic system permitted if public sdwer is - available within 200 100.1.1 Inatalfation will serve: Resi.leaca— COmmerc,ei Otnnr ' Number of living units: Number of bedrooms Character of soil to is depth of 3 frac, _ _ ^Water table depth _ II SEPTIC TANK .-ji O Type;Mlg Capacity No.Comparttiants k PW.'TBEATMENT,PLT.C1 Method of Cliaposal N ` Distance to nearest Vlell____._—� FoundSYon Property Line LEACHING LINE - Ll No. 6 Length of rines Total l0ngth/size . FILTE4 BED - 171 Distance to nearest: Wall Foor danon� Property Line SEEPAGE PITS It Depth Sire Numhef_ SUMPS I L! Distance to nearest: Well Fou nil anon_.�. _ Property Line 1 - 'DISPOSAL PONDS L) I hereby certify that I have prepared this application and 'net the work will be dune in accordance with San JoaQuin county otdinances,state iaws.and rules and regulations of the San Joaquin County - Home Owner or licensed agent's signature ce litias the rollowinb: "I cartify 0-at in Tile porformanca of the work for which this permit is issued, 1 shall rot ' employ any person in such m8nnot as to become subtecl in workman's compensauon iaws of California."COnt:actoi a hiring or sub-contracting signature certifies the following;"I certify that in the perlofma•ice of:he work for which Ih,S permit is nsu0d.I shall employ parstins.suhlecl to workman's ccmpansa- tion laws of California." i The rppliesnt must call for ate requtred inspections.Complulo drawing on inverse sale i Signed -y r • —' �'t��+ � � Title -7 - ? Gat it: —!L- -FOR ^ e ��y r -FOR DE RTM NT USE ONLY APplicay'on Accepted py - Date ~�r Area f Pit or Gr iMi fnspacWn by l Sia �L Final[ syp�ec-tion by �h33f✓�1-�/T<uul, LN/✓�� !>`�r� �P,/� i Appr.,puln Coun Ly FuL+l lc Iloatth ticrvlccs l I ri entaI lkmlf.b Permit/Services 46P - :;an Joaquin, P U [fox 2009, Stkn, rl,l 95201 INF FEE0 AMOUNT DILE AMOUVT f,;41',TTfD CASH �RECEIVED BY f DATE PERMiT.NO. .IHu2rratV ...s,4 20 { %.;OPY - i