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T <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HE TH'i 1 <br /> FBVIRONMENTAL HEALTE DI <br /> 445 N SAN JOAQUIN, PRONE (2 4 O <br /> P 0 BOX 2009, STOCKTON, p� <br /> PER I T EXrI r R R #ff <br /> (Complete in Triplic t <br /> Appllcatloa is hereby -,!: cp San Joaquin :omtty for a permit io construct and/or 'notall the work here:n described. This <br /> aTrpllcatlon i• cede In caap;lance vlth San Joaquin Court <br /> JOaquln Corinty P,;11e Nealth Services. y Urdt^�ncc NO. 549 and 1862 and the Rules and Reaulaciorle air <br /> Job Address .-1 So TCd <br /> Lot Slze/Acreage <br /> r'a Ownsr'a Har♦ r. _ <br /> Phone�.�•S``�7-7 r <br /> Cvnlrict <br /> Addr.i /la�'o[r�tT►.�G_��3SL`fLrcente _ Phone At <br /> TYPE OF WNEW WELL J <br /> ELLIPUMP: ILL A f <br /> v RE"L CEMENT �; � <br /> t of Service Well 0 <br /> - <br /> PUMP INSTALLATION / OESTAUC.ION Li Ou <br /> SYSTrM REPAIR L� OTHER 0 monitoring Well Q <br /> OISTANCE TO NEAREST: SEPTIC TANK SEWER LIMES - <br /> OISPOSAL FLO. PROP. LINE <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL <br /> r INTEtJOED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS ; <br /> - � O Induttnal ❑Open Bottom u Manteca Ora.of'Neu EauvanOn � - <br /> py f'1 Dor ealic/Private, Cl Gravel Pack G TracyTYOs of Casr.q_ Dis•of Wall Casing <br /> }� <br /> 1:1 Other Specifications tg� 1'L�,t1ic er n Delta of Grouh Seal - <br /> i` I I Irr:Oahorr _Appaa. Depth I!Erst«n T"of Croute— <br /> K' urfacs Sail lnsrall d _ _• <br /> Repair Work Oona 67 Type of Pump N,P �r' ' - - <br /> State vvprlt Oa+e— ♦ s <br /> Won Destruction, 0 WON OwrNt« Seallnit Material 4 Depth <br /> Depth 1t12er Wterial i Depth__ - <br /> := TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 ptipglA/Ap01Tl!)N I h - �•w ; " <br /> .• DESTRUCTION I l IND—PIK tYstem parm.ued itprb4c <br /> ov <br /> Installation Will carve: Rasiaenes_ CpmrnereNl a.faoe wrfnm 2W INt.I Other <br /> !; Number Of I"units: ?lumber.of badr0•vns .,b- ;, .�,•`._- - <br /> Ciwact«of sop to•depth of]Ise!-_ <br /> ` SEPTIC TANxD Type/Mfg Caoacnv Water table depth <br /> i� <br /> PKG.TREATMENT PLT.0 NP h •' „''r-' <br /> 0 <br /> Otstana to nearest: Well Foundation p'- <br /> LEACHING UNE 0 No.8 Length of tines h <br /> �/���; ! Y <br /> FILTER BED ❑ Oislsncs to.learast: Wen Four oathcn n <br /> EC µ� <br /> f SEEPAGE PITS 11 Depth Sin <br /> Distanceto <br /> Number l! <br /> ' <br /> SUMPS• LI Oistanso newest: Walt FoundatrOn - <br /> OtSPOSAL PONOS <br /> © Praoemr Line )( <br /> _ -•I hereby Certify INCI her <br /> ` Prepared this application and that the work will be doer n accordance with San Joaquin county adiMneH,elate laws,and - <br /> M1`:� hilae and regWetiab of ter Son Joapuin County <br /> Hat"owner or 6c&-*d Agent's signature condisa the following:"I Certify Choi in the o«/ormanca of The wort fa which this } . <br /> ef►Ylby Any,Prink;n such msnr"r As to becorns subject to wofkmsn't com Permit is issued.I shelf not tttf <br /> uni<ki Y1e pens:tion taws Of Caiilorn s."Contrectoe$hiring a cubcontracting signature <br /> tion laws of Califon do.-i drnfy that in the performance of the work for whKtt this Wrrrtit is issued,1 than employ parsons subject to workman's CAWrOW sa- !• :•�' <br /> f" <br /> '--• • - .The anptkJfttla K rpu'b inapectiona.Compte4 dr -)n r .. - - - •�•: <br /> y i C w^vtg svery ties. p .. �.'• - <br /> -: T Ile Data, <br /> FOR DEPARTMENT USE ONLY z <br /> ARplicatlon Acupt�d <br /> Data r <br /> �= Pit a Grout 4repeetlpn by Oats F'ayal lnapaeti0n bY ! A Date <br /> 4ddidonM Canunsnu: <br /> r n <br /> --------------- <br /> APPllcant - Return all coplen to: San Joaquia County Public Health Services ` <br /> llovironm+;al Health Perait/Servicea <br /> 445 N Saw Joaquin, P O 802 2009. Stkn, CA 95201 •'- <br /> e.�,� FEE - <br /> wF0 AMOUNT DUE AMOUNT REtrITTEA K AECErvED sv <br /> �• ATE lERM1T'NO. :a <br /> l- .ter .��4�..� .-:4ari�<t.rti.iri.�'s.,..+a. -..+r:...,-v��r.e.-.-...w.e-.,�•'.r..ir.�nc � , <br />