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_ i-JR , SRCRAi�EPJ7 SEL 916-8:52 66� Oct o5 ° � 1u 5L �dr� .iJfl F . 15 <br /> APPLICATION <br /> ' SERVICESI ... <br /> SAN J4AQUIN COUNTY PUBLIC HEALTH <br /> m4 V I$ONMENTAL HEALTH DIVISION �"A=i -V1 ! <br /> 'J 445 N_ gTOCKTON, :CA 9 <br /> O BOA 2008,SAN JOAQUIN, PHONE (209)468-3420 <br /> P _ £•� ., <br /> 5202 <br /> - <br /> n r• f� r+ <br /> T _ . <br /> 3 I <br /> (complete n° Triplicate) �.,' ti, . ^..:. 14J. <br /> ApplicatLoa is.herelry mede to sen Joaquin County for a permit to construct and/or install the•+:Tor4"tzcr'ei64escribed. his. <br /> ayglicatioa is p&de in compli.nce with Sia Joaquin County Ordinance Ko. 5L9 and 1862 tuui the Rules and Regulations Of Sacs <br /> Joaquin County Public Health Serrricea. zt: Gi/r rgrnrwLtr' <br /> Sw F <br /> we'Sr Mn�wwn� I+NG Ft.t..Y City STbeKToN Lot $ize/Acreegt <br /> JobAddrest f(,teoo Swrm e-rrt•troot P4Aj4-*y <br /> Owner's Noma goP OIL e<Ow+ P►4J�f Address Z`tll�w[L46 w18186 * <br /> 6 f 88A Phone <br /> Zo <br /> s X104 4�.7�y%dr' t�rvyC .rW CZ47 EfZ ,R'i'o-6$w 66f„� <br /> s Contractor Addres$ Slow �,icense No. Phone t <br /> TYPE OP WELUQUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of 9e;vice Well C <br /> Monitoring tfell f`Y/ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER Q 5 y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ?50 DISPOSAL FLID PROP. LINE <br /> - - — - — FOUNDATION - AGAICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS Zft <br /> I L-] industrial D Open Bottom D Manteca Dia, of Wait Excavation tT Dia. of Well Casi <br /> ng <br /> 0 Domestic/Private D payel Pack 0 Tracy Type of Casing_ VL Specificatiarti: <br /> '. 1'l Public Ns other !1 Delta Depthrof Grout Seal g g-___ . - typo of GroutcgmjD r IrEW rrc <br /> i p 'riQl ' <br /> I I lffmatron Appy <br /> ox. Oe th ! l Eastern Surface Saul Installed by,,, - <br /> 'f Repair Work Dane 0 Ty;sr of Pump H.P. State Work Dana r <br /> well Oestvction C3Well Diameter ...�-- .�.. Sealing Material F <br /> rDepth Bvrr�r+lti ryrlka ���1 } <br /> ' ✓A4rr►1�+^ Depth Filler Ma%arlsal i Depth �+"��•�h�Nhe. 6-21, <br /> TYPE FF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1'I DESTRUCTION t I INC septic system permitted it public Carver rs <br /> available within 200 feet.f <br /> ' Installation will serve: Residence Commofeiai y.__• Other <br /> ' Number of living units: Number of bedrooms , <br /> Character of &ad to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ TypelMfg .� Capacity Na.Cornpasrtrr+enta d <br /> PKG. TREATMENT_PLT_❑ Method of 0400a81 <br /> oistance to nearest: Well ...--...-. _ .. foundation Property Line _.._ <br /> LEACHING LINE CI No. & Length of lines '' TotaP tang;h/site <br /> FILTER BED Q Distance to naarese Wail Foundation — Property Lina ..ter. <br /> SEEPAGE PITS t 1 Depth Silo Number. - —-- <br /> sumps Ll Distance to nearest: We11 Foanda ion Property Line <br />' DISPOSAL PONDS G <br /> ".a i hereby Certify that 1 have prepared this application and that the work will be done in accordan_ca with San Joaquin County ordinances. state lawsone <br /> rule&and regulations of the San Joaquin County ; <br /> 'I Home owner or fcansed agent's signatura Certifies the followino: "t cartify that in the performance of the work for which this pofatit is issued, I shall not V <br /> t] employ any person in such manner as to become subject to workman's compense0on laws of California." Contradtar s.hiring or eut>-contractirig signatute <br /> Fi certifies the following-_1 certify that in the parfotmanee of the work for which:chis parmit is issued,I$halt employ parsons subject to workman's compantia- <br /> tI tion laws of Cafifornia", <br /> The applicant mu r If Iota pee;ions. Compiew drawing an reSerse side. <br /> Signed X. Tills: .,!�• Date: <br /> RTMENT USE ONLY <br /> Applicstiof[Accepted by Roto <br /> I <br /> Pit or Grout Inspection byto Final Inspection by Date" <br /> Additional Comments: <br /> f , <br /> y Applicant - Return all copies to: Sao Joaquin County PitblicHealth Services C +�Q�"` <br /> • Environmental Neelth Permit/Services <br /> ! 445 R Sad Jpriquia, P O Box 2009, Stkn. CA 98201 <br /> FEEAAAQUNT OVE VNIOUNT AeMl"ED CASHCASH RECEIVED 8Y OATC PERMIT•NO. <br /> -INFO Crlyr vrrf <br /> .i 14-26IREV.t/tial �j 1 z72 <br />