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APPLICATION See N <br /> SAN JOAQUIN COUNTY PUBLIC Aj,�'fjtj� SERVICES 500 <br /> ENVIRONMENTAL HEALTH I�I�I�•1 <br /> 445 N SAN JOAQUIN, PHONE ( GM)� U7420 <br /> P O BOR 2009, STOCKTON, �Q <br /> RN R � <br /> (Complete in Tripli <br /> Application Is hereby erde to San J:equln County .'or a Peralt to construct end/or install the work herein described. Th:a <br /> application to emus in coast with San Joaquin .'eunty OrAlnance No. 549 and 1862 and the Bullet mod Re,ulatlens of Pan <br /> Joaquin County Public Health Servieee. <br /> Joe Aeaine S(y0 3 SSSo RO "� c (p pJG <br /> 1' -e �_ C:tv_ �.�_ Lot Slir/AtreaNe <br /> Cwnar'o Noma Ug fvrble,) _Je s't�-S _ Addicts She Phone <br /> v' <br /> l/kt ktG I IE<� Address ,,/A� 6C (vS6 L4/QSr A) Phdna a.SS`-7773 - -i <br /> Contract&�1 __ _LS2=0__ License No. p <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT 71 DESTRUCTION Ll Out of Service Well O } <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER 0 Ppnitdring Well Y <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 QOpen Bono. 'C Manteca D.o. of Well Excavation Dia.of Was Casing <br /> .4 <br /> E.)Donmelk/private C Gravel Pock "C Tracy'--Type of Caving_ _r_ Specifications k,j <br /> I'1 Public L1:OMat fl DNu- Depih qI Grout Seal -f - Type el Great, <br /> i I 1 Irrlpauon _Apwoa:Depth I 1 Eastern Surface Saw inaukad Ey <br /> Rapt Work Done U Type o1Pumps � 'H'P---i _ Sou Wort D <br /> Well Dtvlruttion O Wes Diamet _Stalin,Jistarial-l.Depth <br /> t Depth'— �_ III.ler Material E Depth 1 •'��' - <br /> R <br /> TYPE OF'SEPTIC WORK: NEW MST?LlA9vy =-t- <br /> l :REPAIR rw OOtIION DESTRUCTION I 1 (No avmumnW d re Wam perprWmrwer n <br /> l/ ./ avaibble bH w+t <br /> n]Ila Iwl.l <br /> i� <br /> { "lmlol(itbnti'^•BI wrv+:—F1MidenG ComrMrtul_ Other <br /> Nvmber otBw units:J_- Number of bedrooms _ <br /> Chausetar of ods to A depth of 7 fast AY1 Kks_ —Water table riipth .5 <br /> J / { SEPTIC TANK gr'-Ty Pit dL Go'terx:*ti came;,, 'Cnt6 __,a ` <br /> 1 PKD.TREATMENT PLT.❑ `r : r r , j�,.Mnhod af�1DlaeeeafDistance to nevesC Well�� Foundation I S • rty Line_29LEACHING LINE frl'No.8 Leogro of tibia - D 0 Total utsa (n(I�` - <br /> FILTER DED 0Distance to nesuaC Well-1 Q 6 Foundation I-� mry Line 3C - <br /> r l <br /> F <br /> � SEEPAGE PITS I I_lOepM i Site_ NamGr_ <br /> 1 :SUMPS LI Dialer.to Mar"(: Well Foundation Prdpem laws — <br /> DISPOSAL PONDS O I { } <br /> i <br /> baby comfy IMt I have prepared this application and that me work will bel done in accordanle vvilh San Joaquin county otGMneM,11@10 laws and <br /> ruN <br /> 1 - ,and regulmalcrts of IM San Joaquin County <br /> Home ' <br /> l Hoe owner w licensed agent's signature certifies the[allowing."I certify that In the peilman m •of the work for which this permit N isN@d,I ohne not •I; <br /> I ampler any person In ouch mann0r as lis baeome subject to workman's compensation tsveEol C81f.mi.."Coninclg/a hiring_*b-Contracting sigrleW" <br /> ! _.unpin the toleration:"I certify that in His performance of the work for yvhkh this paten:it Issued I ahan emptily W nobs aubpcl to wwkmxl'a compm" . <br /> flon.Ywe of CNHwm" I- - <br /> -Thsapplicant at can fw am r uir0d 6,•wctions.Compton drswnnp on rower"Wde. t-- -- l <br /> ! ' <br /> r1 1 SpnM% Tine:—�✓@we_(� Dow: b <br /> � - <br /> FOR DEPARTMENT USE ONLY <br /> v�. <br /> r itao>� j AppApplicatione011Accepted by ti�1/ I�� 0,11.� e ,tla <br /> .l.r <br /> PH a Grout Impectiun by Dau Final Inapnctbn bitDia. I <br /> 4 3Y d Addnbnal Comments: - <br /> %' `4 - Applicant - Return all eoploa to: San Joaquin County PYalle Health Services <br /> - <br /> - hnvlrannental Health Iiarvlt/Servieee <br /> +t' ] 445 H San Joaquin, P O Boa 2008, 9ekn, CA 83201 <br /> P alt fir+ _(Ip[•I INFO AMOUNT DUE AMOUNT REMTEO C^SH : RECEIVED BY p1TF PERMIT'Nq. <br /> IN 13-24 IAIV.vgi : <br /> tk�.fj t r tai , <br /> it 14ii <br /> k <br /> { <br /> SSC' <br />