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FROM 11/28/90 18: 06 P . 9 ' <br /> yy K <br /> APPLICATION FOR pB�IT <br /> SAN J0AQUXN COUNTY PUBLIC HEALTH SERVICES tM , <br /> LNVIRONUrNTAL HEALTH! DIVrSION Pi �'4 <br /> P O BOX 2009t 3TOCSTON r CA 95201 E G t V'E�► . <br /> (209) 468-3447 DEQ <br /> (CompAete in Tiilplicate), ENVJR0Nt��NTAL HE <br /> Application to hereby made,to t3ap Joaquin County for a permit to conetrat:t and/or install the Pork til _. ie... <br /> oppilootion Is wade in c0Vllance with Baa Joaquin County ordinance oto. 549 and 1862 acrd the Rules and Reaulat of.son , <br /> Joaquin Co"ty Public Health Services, <br /> AMM <br /> Job AtldraM S t'1f',r_c..� .. _. City 0 Lot Mitts/Acreaze <br /> Owner's Nam Address Phon� _-6 <br /> • Cantsatlnr <br /> �O GEr �f/V1 Address 0 Ulcense Nc.CV-.2(=�Phone <br /> YP@ of WELL/PUMP. NEW WELL 0 WELL REPLACEMENT C7 DESTRUCTION Cl Cut or oaryiae Wall <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER D Monitoring tirelX <br /> r <br /> DISTANCE TO.NEAREST: SEPTIC TANK AJ-S,- .. SEWER LINES 22ge. DISPOSAL FLD. -,djA_ PROP. LINE _26�0. . <br /> FOUNDATIONnl r - ACRICULTUAF WELL OTHEA WELD PITS/SUMPS , <br /> iNTENOED USE TYPE OF WELL PAOSLEM AREA CONSTRUCTION SPECrFICATIONt3 r <br /> Ll lnduatrial Mo,,.� 0 00� bi <br /> n Bottom 0 Manteca Die, of Well Excavation -�, Die. o4 Well Casing �• <br /> 0 Domestic/Prlyate� I� rovol Pack 0 Tracy Type of Casing,_ �tl� •Uz � �`Id PVA- 0 <br /> k;ASpicificitioni <br /> 13 Public 1:1 Other f 0 Delta Depth of Grout $001 r �^ --- Type o1 Grout <br /> CA Irrigation ._..Approx. Depth 0 Eeslern 5urfrtCe Seat installed by <br /> Rtpair Wok Done 0 Type of Pump - -- H.P. State Work Dane _ <br /> well peatructlan . ❑ well Diameter: <br /> Sealing Material i depth <br /> Depth !0 tiller Material & Depth <br /> t <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION R1 PAIR1ADDtT10N CI DESTRUCTION G (No septic system permitted it public aevver is <br /> available within.TDO feel.) <br /> Installation Will lee": ResidenceCommercial— Other <br /> Numbot of living unite: Number of bedrooms <br /> Chorbelet Of Goll So's depth of S feet: ,v Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity "` No, Compartments <br /> PKG, TItEATMI?NT PLT,C1 Method of Disposal <br /> Distance to nearest: Well ____ _ Foundation Property Line Z ;; <br /> LEACHINQ LINE_ Cl No. 6Lennth of lines - - --- . Totalleng!h/s<ixe , <br /> FILTER BED Cl Distance to nearest: Wall .__........� Foundation . Property Lintz <br /> 511044E 0IT6 11 000th Elm — Number is <br /> SUMPS 0 Distance to neareol: Well _ Foundation Propofty Line <br /> OISPOSAL.PONDS D <br /> I hefeby certify that I hove prsparsd this application and that the work will be done In accordance with San Joaquin county ordinance, eters lewd, and < 1. <br /> rules and requfidona of she Ban Joaquln.'CouptY , <br /> or which this psrrrlll is Issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify that In the performance of the work f <br /> employ any person In such manner as to become subsea to workman's compensation laws of Celifornis," Contractor's hiring or ruts cgrttraetinp signature <br /> eartille*the following:"I certify that in the perlormence of the work lot which this permit is issued,I*hall employ Persons subject to workmen's compenas- <br /> 11on Is vfa of Califo <br /> The applicant m st OV•,for all req Clio , Complete drawing on reveerrrb@ side. �}] I t <br /> Si Md Title: r`�P�clQ/�J/ / a L� Does: <br /> - FOR DEPARTMENT USE ONLY <br /> t <br /> Application Aecepted'bY Dote Are$ >` <br /> Pit or Ofovt Inspection by Dote Final Insp'ectian by Data ZS M <br /> Additional Cornmenta: ' <br /> Applicant - Return all copies tots SAN JOAQUIN COUNTY PUBLIC ANALTH 888YICIRS r f+ <br /> INVIROf WENTAL RRALTH DIVISION p$IUIIT/SSIIVICSS <br /> 440 N SAN JOAQUIN, P 0 PDX 9000, BTOCKTON, CA 90201 <br /> AMOUNT DUE AMOUNT A[Mllmeo CASH itECEIVEo fly DATE PEAMI7'NO•, <br /> INFO <br /> 1H 0.24 1NEv.1/*$) V7 <br /> EH 14.28 f} 1 <br />