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APPLICATION
<br /> r SAN JOAQUIN COUNTY ,PUBLIC HEALI�
<br /> ENVIRONIMTAL.HEALTH DIVI } #
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<br /> �11'� 445p QSAN
<br /> 482009INSTOCgTON(209 4�a3�4 q
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<br /> (Complete in Triplicate
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<br /> Application" i4 hereby made,to San Joaquin County for a permit'!to construct`and/or install ihe"vork herein described;' "This
<br /> application is-made in'co�liance with"San'Joequiri'Couitty:.Ordirianre,Ho:l 549 and, 1862�andt.the Rules and Regulations of,San
<br /> a ; Joaquin County Public Health<Servicea ;
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<br /> 4 *]` I'Job Address 9 2 7 /!l v�2 /t/ !'`F:,' ti r�rCity �+�Lt]�/i+Lot Bi ze%Acreage f
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<br /> Owner's Name HYD 1y� Address Sh ,M
<br /> i} Phone
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<br /> jCon Factory i= 0, hhlar �� t t drassc 2°2 N � �N W ",0 license No. 4/�9 � _Phone 31a7�37b
<br /> r-TYPE OF,WELL/PUMPr'- - NEW.WELL ❑ - , _. _WELL,REPLACEM NT n DESTRUCTION Gl Out of Service Well ❑y
<br /> PUMP INSTALLATION ❑ SYSTEM REPAIR i❑ ! j IOTHER ❑ INanitoring swell Utt i
<br /> DISTANCE TO NEARESt`§i0tI6_fAi�lK"""" {` ..t. SEWER LINES ""'} ;" -DISPOSAL FLD: PROP.ILINE i -
<br /> �f FOUNDATION = t AGRICULTURE.WELL OTHER WELL _
<br /> PITS/SUMPS I {
<br /> IN USE_ TYPE`OF WELL i PROBLEM AREA 4 CONSTRUCTION SPECIFICATIONS
<br /> ° C7 lAdustriel ❑ Opary Bottom Manteca ;Dia of Well Excavation ' w Dia.:of Wall Casing "
<br /> * -
<br /> " n ooineitkc/Private ° ~ ❑$G►ave! Packer- -•-❑T11acy - IType'of Cesini, (Specifications' j
<br /> i'l Public .. i:l Other R fl deltaw. { 'Depth of Grout Seal _ I Type of Grout I'
<br /> a I�'l IFriUmion J _._A4protu Depth"t I I Eastern Surface Seal I istalled by r te` ' j I i
<br /> k
<br /> At' it-Work"bone `U -4pe of.Pump= - 1H,P - _Stlafe Work Done
<br /> Y= I+VeIt Destruction 0 We11_Diameter t k
<br /> Sailing Mrtersal L Depth s
<br /> _ .. .. .. Pth �.� d�, .1 g sitter Mlstehi&i Depth
<br /> TYPE OFt SEPTIC WORK: NEW (INSTALLATION -i REPAIR/ADDITION I 1"-'.DESTRUCTION d•1 INo septic system permitted!f public rower is i
<br /> i f�'L 044001- Ir—Ir j ' ;+k 1 h
<br /> available Within 200 lest
<br /> SES P
<br /> �IriililldiSn skill nerve:' 'Residence�:r""Co►nmercia�_' j�Otl,sr/_I""'x ='� �•-"°���Q^---�'s"►i¢ '��-�••�`-�a '-�-�:�.- • � --{
<br /> ` Number of living unity., j 4Number of bedrooms
<br /> x
<br /> Chtirae�er b,loll io a depth of 3 feet. — r r_... ? I M Water table depth .
<br /> s SEP71C" ANK'"" ''' (0 ` Ty�1ri/Mfy " r A` Capaelty'< "° No`Comperements'' t
<br /> PKG-,TREATMENTr PLTf_Cl,_, E _ _. . _ _i r. �.M .�. I .E ;,MlPf�V� }
<br /> ' 1 Distance to nearest: "well
<br /> s Foundation !
<br /> rVFsi LEACHING LINEy, L�,. No. S Lehtath of linea 1 ( I i I -^Tolel kartgth/ei
<br /> r FILLER RED i n ' >aistsnca to nearest l Well Fvundationi s # Pro dQAQ� 1 NTY 3 ( 4 €EE
<br /> t y 3 ..1 PUBLIC HEALTH S VICCS 1 R
<br /> "? SEEPAGE PITS F- s I I f Deplhy i r aSire3 I Num_9MVIt l
<br /> st 'SUMPS ? T 4. Ll Distance to nearest{ t Wells E Foundation) Property Line
<br /> DISPOSAL PONDS ❑ ' - 1: w F -- --1: , t..» } .. ,s ' .. K ' I
<br /> r* �I,heleby efrtkfr that I have prepared this applicatldn and„that.the!work will•be,done In accordance with San Joaquin county ordinances, state laws, and
<br /> rules#end;regdletioris of the Sen Joaqukn County? } I i F
<br /> litirrie ov�rtir ajr hCanseti'egent's signature peitifHlti the ollo+king;i"I certify.ihat Irt the'performance of the work,for which;thie permit is issued; I shall not #
<br /> employ my parson "such tnllnner;as to become subject to workmen i'compensilion lawn of California."Contractoes hiring or sub�contiacting signature
<br /> cartHies the foiowrn ` `I'ceni that in the rformance of work for Which,this�... � fy pe permit is sewed I shall employ persona subject to workman's compansa
<br /> tion•laws of Cilifornle:"
<br /> T to pplics mus or al re tdired ins tions.-Complete drawing.on-reverse side, .�_ I -� t
<br /> - j t ' I "
<br /> ' Signori j t .. .' t" I +tiNe -� Dela:-
<br /> �, .,., r..� } FOR DEPAIiTIV1ENY,LISE ONLY a,:...w, -,:,.�.,-��.....:. . ii,,.-..•: ..,,��,,.._ I
<br /> Application Accepted,by,a 'Y f I "rDaie, 7t r .Asea. j�• ! .� .
<br /> ON at Grout Inspection b Oat �Flnal l goe'etionbv i ' t Date f j
<br /> I Additional Comments: C'� o Crc�G J�1 , ;,o�
<br /> + xv . I"
<br /> r• Applicant IRet6h all copies to 8ati Joa uinr.Coiihty public ealth Services
<br /> `{Environfnental-Health Permit/aet'vicea-
<br /> 446'N Sin doaquiri,'P 0 Box -'2009+ stkn,jCA 85201
<br /> INFO `AMOUNT DUE AMOUNT REMIT-tEDn WS '�'" '"I RECEIVE(] BY �" E OATS' PERi1A17'NO.ro
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<br /> NNW
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