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+� APPLICATION FOR PERIL <br /> SAN JOiliQ IN COMM PUBLIC RHALTH SS@VICSS <br /> 1XVIROKIDWAL BRALTB DIVISION <br /> 1601 $. HAZILTON AVB. , "OKI (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 98201 <br /> 1 YXAV Z= DA:M I86= <br /> (Complete in Triplicate) <br /> AWlicatim to bssebprssda.to See Joaquin County roar a peasrit to s:oastruct eWor install the wWk herein deseribed. This <br /> affumttm Is Made In ca"A'anee frith Sem Joaquin County Ordinance Ho. 549 and 1862 aced the Mules aced Refoutions of Egan <br /> Joavda Cetmty PubUc Smith <br /> , Services. <br /> Job Address - dcS ../..11/t, A&,&- <br /> City u=jjbjC <br /> 4t 81" Acreage Qy� <br /> � y <br /> _ <br /> Owrw's Narhe X XnA I i j",�,�;,�„ Address yLOJ Phonsd <br /> Contractor��,�r.4u '�� J��� kease No.�,��,,�01 T Phdte • <br /> TYPE /PUMP: WELL REPLACEMENT O DESTRUCTION O Out of Service <br /> PUMP INSTALLS ! SYSTEM REPAIR O OTHER O 3 Monitor ithg Well X <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO..�_ PROP. LINE Alf <br /> FOUNDATIOM AGRICULTURE WELL OTHER WELL.PITS/SUMPS AAq <br /> INTENDED USE TYPE OF WELL PROM"AREA CONSTRUCTION SPECIFICATI IS <br /> n Industria O Open Bottom 0 Manteca Dia. of was ExcavU AEM- Die. o/Well Casing <br /> n oonhes tic/Private KGr"Pads O Tracy Type M ssing <br /> 11 Public n 9ther X06110 Depth of Grout Seal Type of <br /> I Irrigation 09-7-Approx. Depth I I Eastern Sudace Seal Installed by <br /> Repair Werk Dane U TWO of Pump H.P. State Work Done <br /> Well Destruction O WM Distnetu agalin Material i Depth <br /> Depth filler Material i Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system psrmacad it public sewer is <br /> available within; leer. <br /> Installation will serve: Residence._.- Conwnercial— Other <br /> NwrAw of blvksg units Number of badroorha <br /> Character of soli to a depth of 3 feet. Wear taw depth <br /> SEPTIC TANK O Typd/Mfg Capacity- No.Cornpowlena <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to,nearest: Wall Foundation- Property Line <br /> LEACHNG LINE 0 No.8 Length of linos Total length/she <br /> FILTER BED O Distance to neerest: Wall Foundation Property Line <br /> SEEPAGE PETS I I Depth Sire Number <br /> SUMPS LI Distance to rhsareat: Well Foundation Property Line <br /> DISPOSAL PADS O <br /> I hereby osrWy that I have prepared this application and that the work will be done in accordance with Son Joaquin county ordinances.aura laws.and <br /> PAN and regulations of the SanJoaquin County <br /> Horne owner or licensed agent':tigemure oestilies the falawi:"I putty that in the performance of the work for which thiepermit is issued. I shall not <br /> w OaW any portion in such wanner as to become wbim to workman's ownpsnsrtion laws of California."Contractive hiring or subHWIllsaft elgnature <br /> certMNa the following.-"I certity that in the pWonmance of the work for which this permit is issued.I shah employ persons subject to workman's coaWansa <br /> tion Hwa of Cawomia." <br /> The SIXACant call for all required inspection. Complete drawing on reverse side. <br /> T s+w+•d Title: Data: <br /> �Oite FOR QEPAR Ui ONLY + <br /> Application Ascepted by Date <br /> Pit or Grout 11 so by Data Final Inspection by Das rZGLI� <br /> Additional Coents: ` <br /> mmLD <br /> Applscaat - Return all crupies to: Ban J Cownty Public Health <br /> Service, Bevirosesestal Smith t/Services <br /> 16M Z. Welton Ave.. P 0 Bou 2mg. Stockton. cA 95201 ' <br /> AMDUW OUE AMOUNT REMITTED CASH RECEWEO ay DATE ►ERWMT'NO. <br /> Qgo <br /> sw:as G7 v` 7 <br />