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APPLICATION <br />SAN JOAQUIN COUNTY PUBLIC <br />ENVIRONMENTAL HEALTI <br />445 N SAN JOAQUIN, PHONE <br />P 0 BOX 2009, STOCKTO <br />(Complete in Trip <br />Application Is hereby made to Sam Joaquin County for a perish to const <br />application is wide in cotVliance with San Joaquin County ordnance No <br />J*84uln County pub"'t H"Ith Servs ea. <br />SERVICEV1a)?5'6 <br />Dwlsloff_� <br />ALI <br />1 IE97Y <br />[ INV#' <br />This <br />549 and 1662 and the Rules and liftigulAtions of San <br />4 . <br />Owner's NimsAddress Ph"'. <br />L lCer',Se NO. F <br />Address <br />TYPE OF WELLIPUMP. NEW WELL C' WELL RIMPI EMENT I-, DESTALICTION Ll out of Service Well <br />PUMP iNSTAILATION C SYSTEM REPAIR C OTHER 0 Monitoring Heil <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ DISPOSAL r -LD.-- PROP UNE <br />FOUNDATION AGRICULTURE WELL _ OTHER WELL — PITSISVMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Li Industrist 0 Open Bottom Ci Manteca iia, of i1Ve11 Excavation .____ Dia. of Well Casing <br />Doitiiasteprivate 0 Grove; Pack* Q Tticy Type of Caving—.— Specifications <br />Public '"I 04hat ("; Doitz clopth of Grout SO -0: Type of Grout <br />Irtloidlion -- Approx. depth 1 1 Eastern Surface, Soul Installed by <br />Repair W*fk Done C Typo of Purnp State Work Done <br />Welt Destruction 0 Wall Diameter Sealing lilateria.1 & Depth <br />Depth Filler Material A Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION , I REPAIR: AODITJON�; t, OiSTRONON K iNZ ;;tic SYSW, Permitted it public sower is <br />available within 2W lost.) <br />Installation will sonov- ResidenceCotrintorcial — Citi)er <br />I X_ Loy_ <br />Number of living units: Number of bedrooms <br />Chatocw of soil to a depth of 3 feet: t —Wat*t table dogith <br />SEPTIC TANK 0 Typo/Mflp 1&4 Capficlty_L�_c e` No, Compartrrionto <br />PKG. T44EATMENT PLT. I-, Mottiod of Nsposal <br />Distance to nearm: Wel! Foundation Property Line <br />LEACHING LINE 0 No. & Length of lines Total length/size <br />FILTER BED 2, Distance to nearest Well Foundation —_ Propony Line <br />EEPAGE PI 5 1 ' 1 Depth <br />LIMPS i� Distance to rwarest Wall Foundation — Prop" Line <br />DISPOSAL fVDS 0 <br />I rareisy ca y 11.I ".1 have Prepared lhvi appl"tion and that Ilea work will be done inaccordan.ee with San �'064uin CO-Unly GnIiin4ft"", State 1". and <br />rules at. Of the San jowum County <br />Hotrio�ow,or licensed agent's sig:iatura certifies tree wtri <br />e following: "I certify that in the 1otance Of The work to, V^lch this Dewire is issued: I $hall not <br />*"V a4 y son <br />in such nwrin&, as to become subject to workman's comperssatian laws of California."' Controctc-'s hitiftnature <br />c4nifilillOw following: "i certify met in the worn of the work tot which this permit is issued, 4, "11 otnploy pet ger fact to k11,14 Co. <br />tion ICalifornia.- <br />I C1 6) <br />A <br />Thea IrlA It must or ad ins ns Complete drawing ort rover" side, <br />1 7"� <br />Signed X <br />This: <br />,.L , - -- - Data: <br />AFOR DEPARTMENT USE ONLY <br />Application Acc#.piad by <br />Pit or Grout IrAW6041 by <br />Additional Comrrionw <br />Applir-itnt - Rataxii all copies to <br />i- 13124 fAtV <br />tH if <br />Is <br />FA <br />MR, <br />: MCA, OF <br />San Joaquin County Pab)i�_� HealthService,,q <br />Environmental Health Permit/Services <br />445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br />1 <br />INFFEE <br />O <br />AMOUNT OtA <br />AMOUNT AtMiTTIED <br />RED By GATE PEAWT NO. <br />�Sw IECUV <br />I — <br />