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e/773 <br /> APPLI'9ATION FOR PERMIT <br /> SAN JOAQUIN COVNTY,RpBLIC HEALTH SERVICES <br /> ENVI TAL UA4TH DIVISION <br /> 1601 E. HAZ T AVE. , PHONE (209)4f 4x3420 <br /> P O BOX" <br /> 2008, STOCIETONr CA 852Q1 < <br /> PERMIT EXPIRES 1 YEAR FROM DATE I SSIIIBD r,,, <br /> (Complete in Triplicate) .: <br /> Application is hereby tsade•to San Joaquin County for a pera>.it to construct and/or $pitqi )aWssti detlCilpflThis <br /> application is made in compliance with Baa Joaquin County Ordinance No. 549 Wtd 100 ti 4W#4ff14f►R 1 140044u"4 Ban <br /> Joaquin County Public Health Services. <br /> Job Address � r��l�r� eitx,� ���� +�►�' <br /> Owner's Name � !'r .L�IL Address _ � IL a.-.-. Phane <br /> Contract F '" /'! Adoress Roe 1K 1 49 2 License "all-, PE1Al1} .F <br /> TYPE OF WELL/P MP: EW WELL 11 � WELL REPLACEMENT Or DFf[�i���IQ�, }� 1 <br /> x PUMP INSTALLATION Q1 'r SYSTEM REPAP 0 OT109.0Q <br /> DISTANCE TO NEAREST: SEPTIC TANK f ---s-- SEWER LINES "!FJ DISPOSAL 0. PROP:IIN$ <br /> t FOUNDATION / AGRICULTURE WELL OTHER WEL ! PIT$!$UAAf► <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT O s <br /> C7 Industrial 0.0 n Bottom 0 Manteca Dis.`of Well Excavation Pla.,at WON <br /> R!"omestic/Private IFffavet Pack 17 Tracy Typa of Casing <br /> I'I Public 1:1 other Il Delta Depth of Grout Sell! p!01 2f9f! <br /> I I ImUation Approx. Dept 1 Eastern $urface Seal Installed h, IFr"r <br /> Repair Work Done 0 Type of Pump H.P. r State Wgr4t iR <br /> .p <br /> Well Destruction gk' Well Diameter Sealing fflte sal A Depth ' <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION'I I DESTRUCTION I I INo tig <br /> ayad All I Rfilm4 <br /> 40 <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Wstel{ d}pth s <br /> SEPTIC TANK 0 Type/Mfg Capacity NA• enq <br /> PKG. TREATMENT PLT.0 M}tfxq� posal <br /> 1 f3fstance to nearest: Wgll Foundation Property L � � I <br /> LEACHING LINE CI No. b Length of lines Total lengthlfisf► .r" . . <br /> FILTER BED CDistance to neatest: Well Foundation <br /> SEEPAGE PITS I 1 Depth Size Number t & <br /> SUMPS LI Distance to nearest: Well Foundation Prop"4 <br /> ,10lial <br /> DISPOSAL PONDS !] e ' ;• • q t ." <br /> I hereby certify that I have prepared this applicatign and that the work will be done in accprdance with $iR #q in re9umv Of ' .#NIS L If els <br /> rules and regulations of the San Joaquin County I <br /> Home owner or licensed agent's signature candles the following: "I certify that in the performance of the 4N4?[k l fr*Jgh 4hiF Wf►IN 1# L.t +ll[ftoi <br /> employ any pe ttltlnner ae to becomtt au jest to workman's compensation laws of California."Oontrgctaes hiring tN"107q ttup ttlgrlattlre <br /> certifus the owing:'1 rtify th4at in a of the work for whip this permit i;issued, I shall smo 'RlffEtllfi ft4fp111141<tM to lstli l -taw <br /> tion laws California." i i <br /> The appy ant m t aN t ste drawing <br /> Signed 4 Title: Q Pate: <br /> > R PAIRTMENT UBE ONLY <br /> Application Accepted by Date (e .► Atte <br /> Pit or Grout Inspection by =� /� Date i?,G. 1 Final Inspection by I1 <br /> Additional Comments: f� P. ��� / /�✓% <br /> Applicant - Return all copies to; San Joaquin County Public Noah <br /> Services, Ravironmental Reelth emit/Services q <br /> 1601 S. R*,zelton AYe., P O Box 009, $tOCYton, CA 950114 i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT'REMITTED' CASH RECte1VE0 yy .}r �yfI,E�TO <br /> IN 14.2e 134 t , <br />