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I , <br /> y d F <br /> I <br /> APPLICATION 1 t <br /> SAN JOAOUIN COUNTY PU131.IC IILALT.I SER�IGFS 1 f <br /> ENVIRONMENTAL 11FALTfi DIVISIONr 1 T; '. <br /> 445 N SAN JOAQUIN,PHONE(209)469-342 I �V <br /> P O BOX 3b8,STOCKTON,CA 95201-0388 <br /> ——__ <br /> f. •J 1' <br /> r <br /> PERMIT �I� r R �� �G <br /> (Complete in Triplicate) — <br /> i Application is hereby made to San Jwquin County for a permit to conmiucl and,'or ingAll the work herrit,t1mrihrd.7hA application i3 made in compliance with San t <br /> Joaquin County Development Title Section 9-1110.3 and Section 9-I 2S.3 and the Rult.and Regutatiant n1 Sar.Joaquin County Puhhc fiealih Scm•ices. _ <br /> Job Address C. rrt1..Lr �t 51%e/Acreage <br /> 1 C <br /> Owner's Name A/dd�r�ess - 4) Phone - -- <br /> CenlfatttN �'IAEIL <br /> ! nefass � ctno r ° PheTYPE OF WELUP ❑ \YELL REPLACEMENT i,, DESTRUCTION L-i out or Servite Vell ❑ ' <br /> PUMP INSTALLATION G SYS7 REPAIR ❑ OTHER ❑ lionitorirg Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES UISPpSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR TION SPECIFICATIONS _ <br /> C1 Industru. f]Open Bottom ❑Manteca Dw 11 Excavaton p[�ia�, oif Weil Casing <br /> CI DorneatiCl Private ❑Gravel!Pack C Tracy Cas of aarng_ ipavftcftPCf~R iafy~. <br /> I'1 Puck f:1 Other h Delta t'ti of Groul Sea$ y,O1 r <br /> I I lurpate)n. --,•Approx. Depth I I Esatvn - S,.rface eel InaWled tfy <br /> Aspsk,Waek Dofse U Type of Pump M.P._ Ste is Work Dons I <br /> Waf Oastnicti¢n O WOR Diameter aealing Natert 4 Depth— _ e,,"�+'-rl I__t,'IC <br /> '�.' :Ot:it r% � 4 <br /> y Depth_ Filler PAterial lL Depth -- P?1 4�(;I-IFAl i l I <br /> TYPE OF SEPTIC WORK:, NEW tN5TALLATIpN REPAIR/ADDITION t 1 DESTRUCTION I I INd aepltc riy'st�tri"perrriyli elf pr. - <br /> -4.'c,s.t ` 'e� available within 2W feet,) <br /> Insta8sliorlwil serve: Rnidence Z Cornmerual shat .. + . <br /> Nuntbat o}lirinp units: Nulnbei of bedrooms <br /> Character of sort to a depth of 3 fit: Water tab4a depth <br /> SEPTIC TANK ❑ Type/Mfg _ q Cepacrty No. Compartment <br /> PKC.TREATIufENT PLT Cl Method o Ot&posal <br /> h Distance to nearest. I /{l IJ- dation Property Lins j i <br /> LEACHING.LINE l C1No.8 Length of lines I <br /> r g T of length/sits <br /> FILTER BED'?-N ra. Distance to nearest: Well ounaii KM! Propert Line /f <br /> SEEPAGE PITS ., 11 Depth <br /> bei <br /> SUMPS L1 Disterlce to near t: ti<yn Faunder..' <br /> ndaroh _ Proparty Line 1 <br /> DISPOSAL PONDS:'. J t <br /> t hweby consly,that I haw pfaasrad Ibis apphcalion and that the work w,ll Ire tlone in accorpance with San JoapLin county ordinances,site levet, and. <br /> rules and regtdattons pf she San Jospuin County : <br /> Home owner Of fl w"d apanYa aigMtufe Certifies the following:"I certify that In the tanforman[4-af the wore for wnith this lac+trvt is issued,I shall not <br /> ampi0y any parson in such mannan as to becamecompensation <br /> subject to workmen's laws of Cet derma.-Conlractcw's hiring or sub-conlrocting signatufe <br /> "r0ias flee follorrinQ:"'l certifj Lha in the peRormence of the work for which this permit is Issued.I&half employ persona subject to workman's connpsnsa- <br /> Non law{of,CW0nI a.' <br /> M ayp4cant must S <br /> TIM tll r-�u in-. � <br /> _ lot apsct' x-complete drawing on reverse wdde.y� <br /> Signed, : "YJNe A'�l Title-_:L�. / � Dere: 1 <br /> - ... k.. <br /> a $ FOR DEPAATMENT USE ONLY <br /> Appl"lion Aeeaptad a Area Jlam <br /> Dale `� `ol`t - <br /> � � T x+' <br /> l�+Yor Grout Enspiclion �Dele� 7 Z Flna+Inefwcrion br e,. 'I Oste <br /> f ddrtioaal Convrwnni ` - ` . <br /> Applicant - 8etura ail'coriee to; San Joaquin County Public Ileallh Scrvi.es 7 <br /> Envuppmtnul liralth PermitlServices <br /> v s 145 N.Sec Joaquin.P.O.box 388,Stockton.CA 95201-03M <br /> ¢ s <br /> •sEf' NI <br /> IMFO AIMOUNT pUE AMOUNT ft[MrtTF6 AEtEIYFp 0Y <br /> 1 s �4 HATE IIAAt17N0. <br /> 29 <br /> ' F <br /> } <br />