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APPLICATION FOR PEPLU I T <br /> SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009 , STOCKTON , CA 95201 <br /> (209) 46e— 3420 OCT 0 5 1995 <br /> PERM11 EXPIRES I X&AR FROM DAus Us EDENVIRONMENTAL HEALTH <br /> (Complete Its Triplicate) PERMIT/SERVICES <br /> RPpllcatlon Is hereby made to Sae Joaquin County ror a permit to construct and/or install the work herein deacribcd This <br /> aPplicatioo is resale in cc=Plla.nce with Un Joaquin County Ordinance No 549 and 1862 and the Rules *.ad Regulations of San <br /> Joa.quit County Public Health Sary1cea. <br /> Caar•6�► clw6 F �^L � -' <br /> Job Adprase ✓� City�t-011 Lot. YiLe/AGrea$e <br /> Owner s Nernst C'LL02— Address 1633 LO (_t)n Asad-±— { 5-4tx.C-fPi. C1SJ1ef Phone�71A� <br /> 0 Zoae. 1&2580 r <br /> Contractor Address e` , License t+lo-A3r..r&8 Phone/ <br /> TYPE OF WELL/PVMP NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ out or Service Wcll 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER J5 Monitoring Well [� r <br /> So./rro�Q/i►r rob cs <br /> DISTANCE TO NEAREST SEPTIC TANK /d , SEWER LINES _ DISPOSAL FLD &1,*_ PROP LINE J21 <br /> FOUNDATION �� AGRICULTURE WELL 4 _ OTHER WELL_jZ9' PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .� <br /> fl industrial O Open Bottom ❑ Manteca is of Well Excavation _ 2' Du of Well Casing 61&n c oC1 <br /> Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing. a Specifications 04 <br /> O Public 1A Other D Dalta Depth of Grout Seal Type of Grout.rr&1N <br /> CI Inw,uon ZC Approa Depth 0 Eastern Surface Sorl Installed by <br /> Ropair Work Dona U Type of Pump H P Slate Work Dona _ <br /> Wall Destruction O Wall Diamotor Sealing Haterinl a Depth <br /> Depth Piller Material E Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION ❑ REPAIR/AbDiT10N 0 DESTRUCTION CJ INo septic system permitted J public sawar is <br /> available within 200 goal I <br /> dation will servo R050CIACO _ COmmoretal` Othor <br /> er of living units Numbor of bedrooms <br /> Character of soil to a depth of 3 foot Water table depth <br /> SEPTIC TANK ❑ Typo/Mfg Capacity_-- No Companmenis <br /> PKG TREATMENT PLT O Method of Disposal <br /> Distance to noarost Well Foundation Proponv Lino <br /> .EACHING LINE Q No 6 Length of linos Total longth/sue <br /> FILTER BED Disiancet to nearest Wail Foundation —__ Propony Lino <br /> SEEPAGE PITS I 1 Depth Sire _.._ Number <br /> SUMPS L:1 Disstanca to nearest Well Foundation Properly Lino <br /> DISPOSAL PONDS O <br /> I hereby candy that I have prepared this application and that the work will be dono in accetooncie with San Joaquin county ordinances state laws and <br /> WIGS end regulations of the San Joaquin County <br /> HOMO Owner or licensed agent a signature certifies the following '1 certify that in the portormonco of the work tot which this porma is issued I shall not <br /> employ any person in such manner as t0 become subject to workman s compensation laws of California Contractor s hieing or sub contracting signature <br /> eortifees the following 'I certify that in Iho perlormance of the work lot which this permit is uaued I shall omploy parsons subject to workman s eompenea <br /> Won laws of Callfoinla " <br /> The applicant mst call I r all re uaod inspeeliono Complete drawing On rovorSo side <br /> signed Title3 ' Data lz <br /> FOR DEPARTMENT USE ONLY Q <br /> Application AGGop10d by Date /0_ /64� <br /> Area <br /> Pit or Groui Inspection by /` Date s^ Final lntpa/cJt_ron by Q Data <br /> AW Comments � 4./ •- (.� � {lj•3 Z ��i� <br /> A t - Rett.ro all co Sea tot BAN JOAQUIN COUNTY PUBLIC HEALTH SERYIcLS <br /> ENVIRSERVICES <br /> 445 N SAN JOAQUIN P 0 BOX MENTAL TI2009on �Rp31=KTON, CA 05201 <br /> FEE AMOUNT DUE wMOViVT REMITTED t RECEIVED BY O <br /> INFO DATE PERMIT NO <br /> m <br />