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l 7 n <br /> APPLICATION FOR P ' <br /> SAN JOAQUIN COUNTY PUBLIC TIS <br /> MVISONMTAL HEALT$ VI <br /> 445 N SAN JOAQUIN, PHONE (2 � Jh 93 7-5' <br /> P O BOX 2009, STOCSTON. JA FA <br /> V <br /> (Complete .in Triplic t -L—Ml <br /> Application is hereby me4e,to Bac Joaquin County for a permit to construct and/or ins ° yid <br /> spplicstioa is cede In compliance with Sac Joaquie County Ordinance no. 549 and 1862 and the Rules aria'Regu3%tloltlaof°Sai1 <br /> Joaquin County FUblie Health Services. // ; <br /> Job Address l gni/ � L ,��'leddl r �=-- city L-(h0606-f" Lot Site/Acreage <br /> Owner's Name _Se Z[!ar'.L.,rd AddressFO7-4 ft <br /> Phone <br /> Contractor Address �"�z ate' LICense No.ft-*—Ow "Phone <br /> TYPE OF WELL/PUMP: OI NEW WELL D WELL REPLACEMENT M DESTRUCTION p Out of Service Well <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom L1 Manteca Dia, of Wall Excavation Dls..of Well'Cning <br /> Cl Oomestie/Privste ❑Gravel PBOI[ ❑ Tracy Type of Casing Specifitatiom <br /> Il Public n other n Delta <br /> Depth or Grout Seal Type W Grocer <br /> I I Irrigation ^Approx. Depth I 1 Eastern Surface Saul Inst0ed by ' <br /> Repair Work Dom L7 Type of Pump H.P. State Work pone_ <br /> woo Destruction C7 Was Oiarnoter SO&L41116 Naterial i Depth - - <br /> DWh truer Material & Depth M <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDiT10N DESTRUCTION I I INc saplie system perrnisiad it public power is <br /> installation will serve: Residence m <br /> Comarcial__-- Other available within 200 fest_I <br /> Number of living units:-/—. Number of bedrooms- <br /> Chw4ctar of cos to s drpsh of 3 fele: Water�utoo depth E0ar� <br /> SEPTIC TANK. 0 Typs/Min CapacityNo.Compartmants <br /> PKG.TREATMENT PLT.O Method of Disposal ] <br /> OWance to nearest: we",_ Foundation Property Ling <br /> LEACHING UNE Jul No. & Length of linea <br /> gth/el=f ' <br /> FILTER BED (3Oiatsnce to nwesf: Wes I e_ I <br /> sn <br /> �.,.� Foundation U _ Property Line <br /> SEEPAGE PITS Depth R f/ Si:e �. <br /> Number ir <br /> SUMPS LI Distance to nonose: WON Foundation Property Line <br /> DISPOSAL PONOS ❑ <br /> i hereby certify that I hwe prepared this application and Ihet the work will be done.in accordance with Son Joaquin county <br /> rules and regulations of the San Joaquin County rug ordinances.stag Isws,and <br /> Honda owner of licensed agent's si inslure oNTirw the following: "I Certify that In the performance of efts work for which this permit Is lawsd,I Bhall not <br /> "Icy my person In wch ntunpr as to became subject Io workmen's compensation laws of Cslifornia.'•Contractor's hiring or sub-cont►acsing signature <br /> artifice the following:--I certify that in ells Psrfosmsnes of the work for which this permit is issued.I shah B <br /> cion W" mpiaY Parsons wbjsct to wrorkmen'a oompsnaa• <br /> M Ctlsfomie.<' <br /> The sppNcant or arquInaposk" patipns. Complete drawing on raver"side. <br /> Signed <br /> Tills: Date: —SPr✓r <br /> FOR DEPARTMENT USE ONLY fb <br /> Application Accepted by � <br /> Drta Area <br /> Pk or Grout Inspsetlon by 0 Dots Final Inspection by Date j <br /> AddNkensf C4nlmsnts: ti - rJ <br /> Applicant - Return all copied to: San Joaquto County Public Health Services <br /> Snviroomental Health Permit/Services <br /> '] 448 R sag Joaquin, P O Box 2009, Stko, CA 201 ��Q �O tow <br /> FEE AMOUNT DUE AMOUNT REMITTED [, <br /> INFO /)/! IyRECEIVED BY PERM17.NO. <br /> MIS.' fN 16,n* V.ni110) !! f 93 - <br />