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3 <br /> APPLICATION FOR MWI.T `�� j <br /> SAN JOAQUIN COUNTY PUBLIC HHALT$ 3j&' I <br /> HNV IRONIMTAL HEALTH D I V I*Ol� �/g <br /> 445 N SAPS JOAQUIN, PHONE (209)468-51919 <br /> P 4 80S 2008 STOC$TONr C <br /> g <br /> T►'ti4 1W ! <br /> PERMIT EXPIRE§ FROM MM <br /> {Complete in Triplica. ell, Iti <br /> Jlpplicatiom is hereby maga to Bap Joaquin County for a permit to construct attd/or install the wart herein deetritted. a <br /> aWliaation is mvAe Its caoliance with Syn Joaquin County Ordinance No. 549 and 1862 and the Rules cad Regulations of San <br /> JOKWn County Public Health Services. / <br /> Job AddreasC7Qt7 GP �Lo4L�r:E h F-�.h City t Lot 31st/Acreage 1 � <br /> Owners Nem"(jjU(!_A h 1A 11t A-jd d i, Add.,, L,flO V/k� /7��__f HCl r_ Phone a q _ j <br /> Contractor r Address �•� rt 7 Ll'�t Y �icensePlo.c _ —Phone <br /> TYPE OF WELT,/PUAAP: NEW WELL O WELL REPLACEMENT n DESTRUCTION YkUut of Service well <br /> PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER 0 monitoring Well E] <br /> DISTANCE TO NEAREST: SEPTIC TANK a42 f-e <br /> SEWER LINES DISPOSAL FLO. PROP. UNE LW <br /> FOUNDATION — AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> CZ industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Die. of WON Casing <br /> C} Domestic/Private Cl Gravel Peck 0 Tracy Type of Casing_ Specifications Q <br /> f'I Public f.}Other t•1 Deas Depth o1 Grout Seal Type of Grout ;er <br /> I 1 Irrigation —Approx. Death I I Eastern Surlat a Saar insioned by ` <br /> Repair Work Done Ll Typo of Pump � _ H.P. tate Wo ons,, <br /> Well Oestructkan `� W"11 Dianteler 8aalit� Material i t7eptlt 1} �p <br /> Depth j3LQ Filler Material A Depth �l►CJ �Li^ <br /> TYPE OF SEPTI WORK: NEW INSTALLATION I P REPAIRrADDIVON t I DESTRUCTION I ; INo septie system permitted if pttbbC sawet is <br /> available within 200 1661.1 <br /> Installation wile stew: RssiderKs Commercial_ Other <br /> Number of living unite: Number of bedrooms <br /> Chwaclw of sell to a depth of 3 feet: Water table depth <br /> SEPTIC TANK C] Type/Mfg Capacity No. Camprrtmants <br /> PKG, TREATMENT PLT,0 Method of Disposal '(� <br /> ! Distance IG nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No,• Length of tines Total lengthIsis <br /> FILTER HED Q Distance 10 newest: Wall Foundation Property Line <br /> SEEPAGE PITS f I Depth —size Number, <br /> SUMPS LI Dietance,to necrose: Well Foundation Property Line <br /> DISPOSAL PONDS C) <br /> I hereby canify that I hew"prepared this epplicalion and that the work will tea done in accordance with San Joaquin county ordinances, itima lows, and <br /> rules and regufalions of the San Joa4uio County <br /> Horne owner or licerasd agern's sipnolure ceetifies the f*Worino•,"I zrortify that in the performance of the work lot which this permit is issued,I shall not <br /> employ&MY person in$L"menner as to become subject to workman's comper"tion laws of California."Conleactoes hiring or sub-contracting signature <br /> certifies chs following:"I certify that in the performance of the work for Which this permit le issued,I shell employ persons subject to workman's cornpones- <br /> lion sawn of CoRk"tls." <br /> The applicant must cap for aft required apsotions. GamPlate drawing on ravers"sill , <br /> Sgnad Tllla: ti`s - Otte: <br /> FOR DEPARTMENT USE ONLY <br /> AppBestion Accepted by Date Ana <br /> Pat tx Gtl <br /> rout irtap"ctlon by Date Final tnspeCtian bye Oats <br /> Addtl6coat Conrnom6. _ <br /> APrlicaot - Beturn all Collie" to: Ban Joaquin County Public iloslth ServicesEnvfy..�r•C�p �����`� � J <br /> iomt,sl Health Joaquin ". P 0Boxt <br /> iaervicen <br /> 645 ttSea2009. St:kn, CA 95201FEE <br /> Y! �Giyyr <br /> aEl <br /> NT DUE AIM4t1NT REWTTTD I:A5H RECEIVED NY DATE PERMIt NO. J <br /> • EM t}'�faaV.lenEl '] HEM f1•LV •Cf4� r✓ yZ��L <br /> / I / <br />