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: - a APPLICATION - ` SAN JOAQUIN COUNTY PUELIC HEALTH SERVICES ENVIRONENTAL HSAI.YH DIVISION "S N SAN JOAQUIN, PHONE t;209)468-3420 '•t P 0 BOX 2009, STOCKTON, CA 95201 p X t .}k; >' C:olnpl�teain Triplicitte) s ti Application is hereby a►de,to r&A Joa4uin county for a pecan to construct and/or ltutatll the work be d+ecribad 'lhia 3 applicatiaz is srdc to tosglianee with S" Joaquin County ordtnance go. 549 and XW and the Rules and RetlWauo°s of 3.n - e Joaquin Corutty PUblie Health services. �� r Job Ad are.t f15444 MITCH RD — City MANTFCA Lot Size Acreage *r r� • 3 4 if. Phons Owner's Name Address "—�`- Cenlracta'NENNINGS B_ROS. DRILL.Address 3525 PELANDALt AVE.LIcenseNo. 29081 Phette5 w TYPE OF M''eLL1PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION {]Out o a ?t;ivlP INSTALLATION ❑ SYSTEM REPAIR R most OTHER Q ` DISPOSAL FLD. PROP.LINE DISTANCE TO NEAREST: SEPTIC TANK 15�t_. SEWER LINES ,.LSG.#n FOUNDATION AGRICULTURE WELL OTH_E_R_WELL _- PITS/SUMPS '� w y' y. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Ll Industrial O open Bottom )LXMamoea Du.of Wall Eacovatiort Dia of WH GsY10 n z. of Casing_ PVC : $lJe�cr<tlnna 150.E- A e 1 xl Oornallicl Private LY Gravel Pack Q Tracy Type . I -----= Tres+d Orout� . n Other n D+Ita Death at Grnut 5nal, F► `I �, -CO."i _5 EROS_ ORILLIN .� I i Irrigation /'e Approv.Depth I I tricorn Surface Saal Installid_bY Raa/Ir Work Donn L3 - Type of Pump H.P. State Work Done'_ Sealing Natertel i Depth 43 j Well Ontructian Q We#Diameter e. terial i Depth OeDlh Tiller fla TYPE OF SEPTIC WORK: NEW INSTALLATION I t REPAIRIADDITION I I DESTRUCTION I I INo aeptte system ryNTillad A ptsbac earv«r liJ r _ __ _ eve" M within 30D w4t.1 - r• Installation wig serve: Ras+denea_ Commercial.T Other a qq i Number of living units: Nur,�ar of trsdraams " r Character of eo8 to a depth of 3 feat: Wow tsbM depth SEPTIC TANK O TypalMfp Capacity e - .' IlAathDd et Dhpaasi 's:x 1 • ��S PKO TREATMENT PLT Q 1 k;r� ar Dirtonce to not"Ir ! won Foundation ProAsM LLta v` R I � G►£. Total lengthlsks LEACHING LINE" ❑. •No.A Length of fines ._ yf ' FILTER BED Q Distance to nearest: WAIL Foundation Proferty Lina }; SEEPAGE PITS 11 Depth Sire Number SUMPSLl Distance to nearest: WNI Foundation _ Propstfv Lina------- DISPOSAL PONDS ❑ t y H ew�sil I hereby certify that I hove Preparotl this aGixliceflan and th.!the�+olk tail:be done in accordance with Sen Joaquin courtly otdmancea,eWte tlwe +n+d rules and regulations of the San Jorquin County r„a m c HtxtN owner a licenesd agent's signature cenifin the foEowinq;"t c!pnify that in the performance of ft work for�#kh irk pertt4f N iawtsd.'IAA slat x a 3q} employ any peraon in such erfortnsr as to become subject to wort-non's compenaition laws of California.-ConMaettx s hirh►a M sulfCattFaetfrtB tiprlstura certifies the following:"t certify that in the Deformans !of the work for which it permit h Issued,I shW employ peraana subject to workman a Compansa _ x 1 tion Iowa of Caiifomia. _ The applicant must can for an required inspections.Cpl to drawing ext reverts tid�, r - :4 f- 8 itle: Date:- 1 OSwrw EPA11111411ENT USE ONLY `. Application Accepted tri �- __ Dau Area u 16 Dew Pit or Grout Inspection by Dsfa Final Inspection b q < :• f Addhlonai Comments: Appllcar,t - Return all topica to. San JOagettt County publt,c Health services Eaviroomental Healih Permit/servicer _8tka, CA 911201 .� - 445 N San Joaquin, P 6 Box 7009, t NtCiNED�Y DATE PER1rvT 110. FEE Nrl) AMOUNT REMITTED CASH _ INFOAo ¢, IN lYr•laay. h € t1t te•s 3U:303 - r,�• yCF^r