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. APPLICATION FOR PEMIT <br /> SAN JOAQUIN COUh= PUBLIC HEALTH SERVICES <br /> ENVIRONN32MLL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 PA 1"1wF -. <br /> P 0 BOX 2009, STOCXTON, CA 95201 J�Zcz jV 1 4� <br /> MAY 2 6 <br /> (Complete in Triplicate) P(18NC0AQ�,r1N�1993 <br /> EN Application is heretsy arde.w San Joaquin County for a permit to construct wWor :Uwta.0 the �1r�'his <br /> application is made in e=Wliaoee with Slam Joaquin County Drdina.oce llo. 50 acid 1662 and the Rules <br /> Joeaiulz County Public Health�1Serricea. .� D1V/S10'V <br /> / <br /> Job Address ` 31 SOS " ' y"I;- �itY Smch&y Lot Size/Acreage <br /> Owrter'a Name 6�= 11�'I � Address �y "`ter Phone Q- <br /> Contractor <br /> Jb/ 10IQ77aN1t2 Address 3I S n UI'.'AC. G�i1KlQ License Nd72 Phone 7 <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT 0 DESTRUCTION D Out orlBer-rice 11811 ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER Q Monitoring Veil <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMS AREA CONSTRUCTION SPECIFICATIONS <br /> C7 industrial ❑ Ow8artom D Manteca Dia. of Well Excavation=4 Dia. of Wagarnq <br /> n Doroesuciprivats ❑ Grjvel Pack ❑ Tracy Type of Casing Specifications <br /> M Pubk tt�er ato►u brn aj n Dena Depth of Grout Seal Type of Grow <br /> I I Irrigation 466ippiott. Depth I 1 Eastern Surface Serf Installed by <br /> Repair Work Done 0 Type of Pump A/* H.P. Nktats Wort Pone A14 <br /> Well Destruction O Wet: Diarnew Z in cit Sealims Material i Depth e/_ssraJ'1f ' 7brYrt� <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 lost.) ` <br /> Installation will serve: Rasiderres_ Comonwrt:ial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to it depth of 3 feet: Water table depth <br /> SEPTIC TANK. D Type/Mtf Capacity No. Cornpartments <br /> PKG. TREATMENT PLT. Method of Diaposat <br /> Distarta to nearest: Well Fouridation Property Lin. <br /> LEACHING UNE ❑ No. i Length of Eines Total length/site <br /> FILTER SED our%mlwn Property Lina r <br /> SEEPAGE PITS I I Depth size C. <br /> SUMPS waif Founoeuon Property Lire ` <br /> NDS O <br /> I hereby certify that 1 he" pre Bred this apoiicstion and that the work wilt be done in accoroanca with San Joapuin county ordinances, mute laws, <br /> rules and regtrlatkxw of the San JWpurn Caunty' <br /> HOI owner or ficertaed aq.rtt s sipnettire osrtifw the following: "I certify Thai in the p rlormance of The work for vrhich this pemril is issued, I shall not <br /> 4111PIP10Y MY twepn in Such rrmwv sr as to bezorm sublsct to workman's compensalion tows of Calilomia." Contractor's hiring or sub-conuacting smnature <br /> CWWimm the following:-1 certify that in the pwlornwtcs of the work for which this perms is".%ad, I shall employ pereom wbtW to workmen's compensa- <br /> bon irwa of C4ld0n-ia." <br /> The cad for all drawing on reverse aide. d <br /> TWO: G -e� ze 4 /s Date: l j <br /> FOR DEPARTMENT USE ONLY O <br /> cce1 <br /> Apted by ` ' 1 pate 3 !3 Area 1 <br /> Pis or Grout Inspection by Date Final Inapection by Date <br /> tW" Cw rnents: A-(L✓ (o �� ?I/V/49S <br /> Appiicast - Return all copies to: Sas Joaquin County Public Health Servicett �t �� n <br /> Envirowpental Health Permit/Berrie*■ RECEIVED ;;;i i U 139; <br /> 445 H San Joaquin, P O Box 2008, Such, CA 85201 <br /> FEE <br /> INFO AsAOUNT DUE AMOUNT REMITTED CASH + RECFArED Illy DATE �f q PEl&AMNO. <br /> tar tsar rluflr.I r x u 17 __ ! <br /> e..tea <br />