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ESiIIa �iir PmHENTO TEL 9jiS52-6688 Oct 05 '9 10 .52 Ne .007 P 15 <br /> APPLI CAT ION �•-!' 0 50 . o E <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION OCT 4 6 19f� <br /> 445 N SAN joAQUIR, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON CA 95201 IAN iti <br /> r'I`=ti-ir HEA1 T+I = <br /> EMU EXPIRES YE S fFsiliJPrIF�; ;r I+l n1 s,. <br /> (Complete in Triplicate) <br /> Applioatlon as herebtr made to San Joiquln County for a permit to construct and/or install the work herein do,ortbed. To-is <br /> aPP"cattop 1e made in anllgrliance vitt Sap Joaquin County Ordirtareoe Ho. 549 and 166e and the Rules and Regulations of San <br /> Joequta coeursy Public Heel h 8 traces. <br /> Aj lv CO OL A VVL d0 <br /> Job Addrssa _Hdmnsm. Ls%.n a !►" wa3r L.4mE' City „$MOX TON Lot Size/Acreage <br /> f 161,p0 60rj?"CaurbiL PA"6-14Y to Im 310e., <br /> owners Norne It? 0rL Goy! AddressVjr1u lLd! wiA qIrtad Phane[J_eQ mq-S446 <br /> , ne io.cr //D�' /.1'r 4-0*V7, LiS'2a .s�'e�Ga�'��Qd3 <br /> Contractor ss bice <br /> TYPE OF WELL/PUMP 1 NEW WELL O WELL REPLACEMENT 171 OESTRUCrION l❑ out of 5arriee veli <br /> PUMP INSTALLATION ❑ SYSTEM RtEPAIA C7 OTHER ❑ Monitoring Veil <br /> OISTANCE TO NEAREST: SEPYIC TANK SEWER LINES ' DISPOSAL FLO. PROP. LINE 149 <br /> MUkoATION r AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TY E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O <br /> C7 Industrial ❑ Open Bottom ❑ Manfea Dia of Wall Excavation pia of Watl Casing 2# <br /> (I Oomettle/Prrvate 0 Or" Peck 0 Tracy Type of Castno_P[G Specifleattona ��^11 40 <br /> I I Prrblre r�(atrier I-1 Delta Oapth of Grout Seal ___ 340 Type of aroul B rr1rr <br /> t I IrrrOat+arr Approa. 000th I I Eastern Surface Seal Installed by---A 0"ZY49a= �W <br /> Repair Work pent U Type of Pump HP P S ate Word 00#11 ._.__ <br /> Wep p*struetion ❑ Watt Diameter .. $aalang f(atarial !� DeTrtb %V- -515, <br /> Depth Piller lfaterlal 4 Depth O--se •1 <br />`-';f7'E0FS90tiCW0AK rIEW I'NSTALLATION I I REPAIR/AOOITION( I 0ESTRUCTION I I INa seprro system permhled 0 p,ftrlle savwr it <br /> aysdable withln 200 feet I ®® " <br /> , f <br /> f �aeatwn will earn Resfdence..r,, Comrnereral ,_ Othar <br /> .umber of living unna' _ Wmber of bedrooms @a, <br /> Character of soli to O depth of 3 lteat: Water table depth <br /> SEPTIC TANK 0 T /Miq <br /> 1''pr Cepedty NO. Contpennrente <br /> PKG TREATMENT PLT Ll Mathod of DWM$#f <br /> 8itance to nearest. Well ------__ _ Fotend$lbn Property Line <br /> LEACHING LINE C1 No & Length of lines _, Total length/site <br /> FILTER BED ❑ Distance to nearest wall Foundation �_ __-. - Property Line <br /> SEEPAGE PITS 1 i Depth Sipe __, Plumber <br /> SUMPS U Distance to nearest- Well _____� Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I haf*by Certify that I havd prepared this application and that the work will be done In accordance with San Joaquln County ordinances atete Laws ar+c <br /> rule• end regufatlone of the S&AJoaquln County <br /> Home owner or liesruad agom's signature oerediett the f000v V- "I certify that In the peHarrnance of the work for whkh this permit Is Issued I shall nor r <br /> e#1eploy env person In such"nnar as to become subwl ro workman's compensation lawn of Calilornis'"Contractor a hldnp Or euaContracting slgnatwe <br /> certifies the following 'I certify that in the ped0frtla606 of the work for which this permit is uaued,I shell employ persona subJact to workman's cortlpensa <br /> tion laws of Catlfornia " ;f <br /> The atiollcsnt Musor <br /> Ire ti a Complete drawing on reverse side <br /> mat <br /> Signed X <br /> Date. <br /> �0 PARTMENT USI~ ONLY <br /> APPlresrlon Accepted by pateIlt-WAAra <br /> i x"'Grout Inepactlon by Oate Fln,l Inspection by OstaZ <br />`� Tut C`orttm"ta. ' <br /> t-2M"1y gplict11t - Return all copies tot Baa Joaquin County Public Ue*ltb 9erviaes � iJ►� <br /> Environmental Health Permit/Services <br /> e4$ H gad JOaQttiff, P O Bort 7009, Btka. CA 98901 <br /> 041r AMOVfVT OlJF AM Figm(rreoCX <br /> RECEIVED IlY <br /> Q AASH '/ECEIV JGATE {�PERAAIT NO <br />