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APPLICA71ON FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC aHALTE SERVICES <br /> VIRONMENTAL1601 E 8A2 LTONN AYE.. PHONE (209 468-342SALTH DIVISION QU �' E' <br /> P 0 BOX 2009, STOcETOH, CA 95201 <br /> ES I Y6 R <br /> (Complete in Triplicate) <br /> Application to hereby Ca tp S&L voagwid County ror A perait to apnetrugt awdlor 1rutpll the work ber&in decertbed. This <br /> appliratidn it mAde Lac +ilan_e vlth Bah Joaquin Caanty 0reira.r,Ce No, 549 end 1662 and the Rules and Fteguiettanc of Slktl <br /> Jor.quin Cowrty/Public beslth Serrlcer. <br /> Jab AddrRff `JLLe/ACreagr Z;?0'0 /3' <br /> or <br /> Owfler'a Nbn%e �/}'fSr Andress �} phgrw <br /> Contractor L.� _ Aatlress ry LY' t +- /. . Li.ense Nc� Phone <br /> TYPE OF WELL/PUMP- NEW WELL D VvfLI RFPLACEMENT ❑ DESTRUCTION ❑ Gut or Service Well Ll <br /> PUMP INSTALLATION G SYSTEM REPAIR U. OTHER Q Monitoring Well �3 <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLU, PROP, LINE <br /> FOUNDATION A(iAICULTUJ tE WELL ._ OTHER Wfti. PITSISUINpS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [1 Industrial © Open Bottom " Mlintsca Ore of Well Extawiion MA of West Caslrrg <br /> l 1 DamaSliclNivile L: Grival Peck C1 TraGy Type of Casing $peCir"14Qnl <br /> I P0bllc 1-1 Othel f l Della Oaplh of Growl Seal Typo o•1 Growl <br /> l 1 IrrlSatbn — Approx Depth I 1 Eastfm Surface Saul Installed by � <br /> Ripka work Done L3 Typo of Pump H P _ _ State Work Done <br /> well f]esrruction iA well Diameter Mina Yaterial E Depth <br /> Depth Filler Material k Depth <br /> TYPE OF SFPTIC WOAXu NEW INSTAL LATION I I +iEPAIRIADDITION 91- DESTRUCTION I I iNo saptrc system Parrrrrped it prrtlk r:vwnr n <br /> lvallable within.200 Igyt,l <br /> Installation will verve- flasidetsca —_ Commercial _ ❑thel _7 1 ,3 <br /> Numbet of #vrnq units; fJurnhcr eoe <br /> ChInaciar of soli to a depth of 3 feet) I Imdrm _ Wa;sr table depth d t f <br /> SEPTIC TANK 0 Type;M19 _ cepecrty, No, CompartmenSa <br /> PKG. TREATMENT PLT. L� Method or D}Lpoaat _ T� <br /> (}islancr to rwerest: Well Foundation _ Prrry-aorty Line }] <br /> LEACHING LINE LI Na. d Length of liner -�JyL �� r Total lanytt+lsrii_ " — � <br /> FILTER 9EO 0 Distance to nosrast: Well Founlietlors . �_f Prnpeny Line p►F <br /> G <br /> SEEPAGE PITS 1 r Z i 3 (D r' <br /> Depth Sire �- Nwntrer _ <br /> SUMPS i.I Distanceno to sloiGl Wallt' i Foundation Ira' Propony Line Y '1 <br /> DISPOSAL PONDS [_l <br /> I hereby certify that I haws prepared IN%apllhcaWn and that Me work Will be done In accordance vMfr San Joaquin coy,nty ordinances, stale la+vs. end <br /> rules and rrgulatldnz of the Sah Jp►quin Cgy,pty <br /> Home owner ar licensed lgenl's sigriture Cenilrers the IoNowing "I Csnity Thal in the pdrI(XMilnC1 Of the Wear tot whlCtl Ihrs permit is dsurd, I shall not <br /> empfay Any person in such manner as to become sobAct to workfneh•s mnVanealion laws of Calalarnii." Dpnlraclors hiring at sub crmtratting signature <br /> ea►triras the iplowrrlg: "I Canily that in the performance of the work lot which this permit Is Issued,I shell employ persons aubpci to workmen's companaa <br /> Sion laws of Cahlotnra." <br /> The applicant rtxrsl call for elf r uir rnsprCtiona Complete drawing on fee]vsfse fide �f <br /> Sipnad x ��r� _ Tida; C�G!�'i!S Dare: <br /> FOR DEPARTMENT USE ONLY <br /> Applicarion Accreted by Cola —^ Area <br /> or G.oui inepecWn by / _4 Aate Final Inspowien#1' DAia <br /> Additignal Comments: <br /> Ayplicant - Facture all coplot, to; Saa Joaquin County PutalLc fleelttr <br /> Eervices, J'nvlranmen:al Flealtb PeraitlService■ <br /> Ilk! E. Ilanelt= Ave., P G Box 2009, $teckton, CA 95201 y' <br /> Impo <br /> FEE AMDLINT ❑UE AMOuNT FlEmiTTEO CxJL FiECEIVEA my DATE PERMIT NO. <br /> . EM tyil tREY-t.■ar - TD <br /> tH:a-aa ICJ ! <br />