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APPLICATION <br /> .Ic1AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> K-W RONMENTAL HEALTH DIVISION <br /> 11;, N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> MOW, EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is henry lade to Tan ;<ululn County for a poralt to construct and/or Install the work herein deecrlbed. This <br /> application to ssld- In coq+]tare• vfrh ;an Joaquin County Ordinance No. 549 and 1862 and the Rules and Rebulations of Ban <br /> Jnanui� C,wan ty T1,s lit H�\glth ?e rvlr►a, <br /> _,,b Addrete ,/ ry _---- n��✓�-.1-J City r�S2LV'J_ Lot Slte/Acreage <br /> Owner's Name <br /> My<.-c"/x�-- - Add,ssii 4���/_L_(� A� Phone <br /> ! <br /> L,Crnle No.t,0v v:2-q-Friona 1-72 7 <br /> TYPE OF WEI L.PUMP NL.\ WELL WELL REPLACEMENT F- DESTRUCTION L'Out of service well L j <br /> PUMP INSTALLATION L; SYSTEM REPAIR L' OTHER O Monitoring well CT <br /> DISTANCE TO NEAREST SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP LINE J <br /> FOUNDATION AGRICL TORE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE Or WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I I Industrial CI Open Bottom FI Manteca Du of Well Excavation Dy.of Well Casing <br /> f 1 DomesticPrivate C1 Gravel Ped 11 Tracy Type of Casing_ Spactflcatrons <br /> I'I Public Il Other I I Delta Depth of Grour Seal Type of Grout <br /> I I Irrr,/ahon __Apfwo■ Depth I I Eastern Surface Sod)Installed UY <br /> Repair Work Done L7 Type of PUMP _ H P. Stats Work Done_ <br /> WON Destruction O Well Diamli Sealing Material 6 Depth <br /> Depth Filler Msterlal & Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION l REPAIR'ADDITION I I DESTRUCTION 1 I INO asptrc srslem permrtutl If jx bk sevyet is <br /> / Ivaiable wrlhin 200 IMt.I <br /> Instalotion win serve: Residents ✓ Commercial_ Other <br /> Nurturer of Gvwig units: /1 Number of bedrooms�I n <br /> Character of soli to a depth of 3 fast _r.v,Cl"y L"-re/ —Water table <br /> SEPTIC TANK yType/Mpg e� <br /> , <br /> _iP !- L Gant it-t'L Capacity /Z:06 No,Compentinaits <br /> PKG. TREATMENT PLT.O '^F Method of DTo" ) : <br /> Distance to neartist: Wan �s)D Foundation_�,f� Property Low <br /> LEACHING LINE No. A Length of lines o TotSl length/sire j <br /> FILTER BED Cl Distance to noAresl: Wen��_ Foundation_ S Property Llaw <br /> Qi <br /> SEEPAGE PITS I I Depth _1_!,1_Sir* Number, <br /> t <br /> SUMPS 611/ !Distance to nearest: Well��� Foundation 4— Progeny LHw M�L <br /> DISPOSAL PONDS O <br /> I hereby cenify that I hews prepared this epplicalion and that Inc work Will be done in accordance with Son Joa101lin county ordinances,slate Iowa,and i <br /> rules and regulations of tM San Joaquin County <br /> Home owner or hCensed agent's signature Cymiflas the following, "I comity that in the performance of the work for which this pemrt Is Issued,1 shall not <br /> amiploy any person in such manner as to;scorns subject to workman's compensation laws of California.-Contractor's hNNig or sub-contracting signature <br /> certifies the fosowwV:"I Comity that,n the rorformance of the work for which this permit is issued,I shall employ persons subject t0 workman's CO"V"U. - <br /> Non lays of California." <br /> The applicant must can for all rs uved-nspectlons. Complete drawing on reverse srde. <br /> Signed Title: 4 td Af IT Date: k <br /> F DEP MENT USE ONLY <br /> Application Accepted by Date A. [ <br /> Ph or Grout inspection by Oats final Inspection r Dat" <br /> 7 <br /> S <br /> Additional Comments: <br /> Applicant - Return all —;,1— tri: San Joaquin County Public Health Services <br /> E.nvlronmental Health Dere!t/services <br /> 445 N San Joaquin, D O Bo■ 2000, Stkn, CA 95201 <br /> IEEE AMOUNT OUF AMOUNT RRFF/M,TTEO CK I <br /> CASH RECLINED BY DATE IERMIT ND. <br /> 24(REV <br />