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MAY 22 '95 12:59PM ANDERSON CONSULT INGPLICATILIN <br /> P SM9�AQUIN COUNTY PUBLIC HEALTH �WTCES <br /> ENVIRONMIINTAL EKALTE DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCRTON, CA 95201 <br /> PERMIT MIUS 1 YEAR BRAE DATE 136 <br /> (Complete 3n Triplicate) <br /> This <br /> Appllcetiea is heren <br /> by UIC.1l San J011VIA County Sar a Perrdt t* ConatruCt and/or install, the uoxk herein described. Sain <br /> appm <br /> licatdao is de llaace in coolwith Dan Joaquin County Ordinwet Na- 549 and 1862 and the Rulee and Reguiatlona of Sous <br /> Jtxulela County Public Health Services. f� <br /> �' 5-C. CAIrT Irfl I I1 City "_ _�—•..— Lot Slae/Acreage <br /> Jap AtWress /1�� 9 (1 �/ +.- �� <br /> L;+41) rv, .0 S7 A r'!'t1m/AA9fQlM q A1� Phone r <br /> Gwrlal'a Nenlde ��1 n Atldness <br /> Contractor Fr �U�T� & Address a 0, #evi N- License Na:��5' *416-7 — 3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WREP <br /> ELL LACEMENT Fl DESTRUCTION 0 Out of Bernice vel ❑ <br /> NrgrStaring Fe11 Ej <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER %_ i$� / <br /> DISTANCE TO NEAREST; SEPTIC TANK �— SEWER LINES DISPOSAL FLD. Pill IN Y <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSJSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll industrial P Open Hutlom O Manteca Dis. of Well Excavation Dia.of Wes Caning <br /> n Damellicipri am 0 Gravel Pack ❑Tracy Type of Casing Specifications <br /> I"I Public CI Other ❑ Dena Depth of Grout Seat Type at Grout <br /> I I litigation —App ox- Depth I I Eastern Surface Seal Installed by <br /> Repek Work Dow ❑ Type at Pump H.P. Slate Work Done <br /> wall Destruction ❑ Welt Diemenr Healing Rateriel A Depth�� - <br /> Depth f .: r S neer Tfaterlal a Depth CPjtrrr{"S ftrr fiw c�C <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDITION I I DESTRUCTION I I IND septic system Parmaled It public sewer is <br /> available within 200 imt.l <br /> healonstion will sewn: Residence— Commercial — Other <br /> Number of living units:_ Number of bedrooms <br /> Character of son e•depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Comparlmenn <br /> PKG-TREATMENT PLT.0 Method of Disposal <br /> Distance to neatest: Well Foundation Progeny Line <br /> LEACHING UNE ❑ No- d Length of linos Total lengthlsiza <br /> FILTER HED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 I Depth —-Sine Number <br /> SUMPS LI Distance ro manes: Wen Foundation Properly Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby carlify that I helve prepared this application and chat the work Wig be done in accordance with San Joaquin courtly Ordinances,list*laws, and <br /> rules and regulations of the San Joaquin County <br /> Hama owner or hcensad agent's signature carsifiec the losowing: -I canny that n the performance of the work lar which this permK is issued, I Shea not <br /> lemploy any person in such shoveler as to become abject ic workmen's compensation lawn of California.-Contractors hiring or sub-contracting signature <br /> certifies the faaowkhg:"I certify that in the paroffroi tce of the work for which Chia permit is issued, I shell amploV pandna subject to workmsn's txsmpenw- <br /> lion lawn or California-" <br /> The applies for p r�qu ee kucaCtions- Corrylate drawing on reverse side. yy <br /> Signed 7� Title: ed and ggeo-__ __— DAN: <br /> 5 . [,r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dan Area <br /> Pit ler Greet Inspection by Dote Fine1 Inspection by Den <br /> Additiwel Comtents: <br /> Applicant - aeturn all copies to! San Joaquin County Public Health Services <br /> Hnrircie ental Health Penult/SCrwlccs <br /> ads N San aoaquln, P O Hex 2009, Sckn, CA 95201 <br /> FEE AMDUNT DUE AMOUNT REMITTED Cx RECEIVED ev DATE PERMIT NO. <br /> INFO CASH <br /> Fe ri•h IREV.yn6r <br /> EN Rae <br />