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=99,.3 - IS -57 $Etc 647 <br />SARI JOAQUIN COUNTY PUBLIC HEALTH SERVICES AD q5/3 <br />ENVI iENTAL HEALTH DIVISION A 39,44 <br />445 N SARI JOAQUIN. PHONE (209)488-3420 1 <br />P O BOX 2009, STOCKTON, CA 95201 Nanlq# <br />Pk id1T E riI RES 1 IM FRQU DAA ISSMWoy4 <br />(Complete in Triplicate) <br />Application 16 hereby' wde,to BOA Jzeagnin County for a permit to construct and/or install the work herein described. This <br />application is mAe in C00011"00 with San Joaquin County Ordinance Ko. 549 &M 1552 artd the Rules cad Regu3AtiO4e Of San <br />Joaquin County <br />%Public health Services. <br />Joh Address i le M xy -& City 1,afi, $J1WJAoresge <br />Owner t Na" �( �'' �+ ;? �.�L ° H&- . 150102le phone i &'__9 <br />')I <br />t <br />�r��r :�r:s�^"�, lr:��� 1��,� �*r+►.#:L�N�T!'7r��!'?','srf�;�1[-" <br />9 NEW WELL O WELL REPLACEMENT i, DESTRUCTION CJ out Of Eerv'14* well ia <br />PUMP INSTALLATION D SYSTEM REPAIR U OTHER D l4nitoring wall C7 <br />DISTANCE TO NEAREST: <br />SEPTIC TANK . <br />SEWER LINES DISPDSAL ILD. <br />PROP, LINE <br />OArt <br />TYPE Ott SEPTIC WORK: <br />FOUNDATION <br />AGRICULTURE WELL OTHER WELL <br />PITSISUMPS <br />q►`` <br />INTENDED USE <br />_TYPE OF WELL <br />PROBLEM AREA CONSTRUCTION SPECIMATIONS <br />Ottw <br />ave witffht X0 feat.I <br />C? Irdustlial <br />Cl open Bottom <br />D Manteca iiia. of W" Exclovatiofl <br />012. of WW Casing <br />r,: Donmtic/Priwaia► <br />0 Grp Pack <br />D TracV Type of Catong,. <br />Spea4abons <br />lA+ w table depth <br />)V Pubk <br />Ci 4dw <br />n D%R* t)epth 01 GXOUt SWI <br />Typo of Gratz <br />0 <br />1 I Itretlsrwn <br />,,.,,,,. Apprax. Oept <br />1 I Eatman S acs Sew Instated by <br />Rspair work Dora W, <br />Tww at Pt -v <br />� N.P. .� __ Stals <br />Property Lima <br />WON Destwcbw 0 <br />we# C}iar"Mr <br />Sesi.ine 96%erial A nth <br />I rwOby cenity that I hVA prepared this application and that the work will be at accordance with San JOSS in COur#y ora aa. stats taws, and <br />rales and raquiatwo of the San ,10"Win County <br />"Orin owner or licensed sg&Ws siW%afura colifiet tate foiiovwV� "I Cartity that In the parforou"o of the work for MAtictl t sis own* is muw, I aha not <br />atnploy any Person in tush trlAMW as to bse4wo stmt to workman's compsoastion hwA of Cakfornia," Coatr*ctW# hirin0 or sub o6afracting signatura <br />candies the fasuwitg; -I carrafy dor in dte p&jbr wx4 of the work for which titb pwait is issued, i shah atnPioy puattrat aubiM 16wodt"Wil coftw" - <br />tion Is" of Ca"60 ia." <br />Tire applicant rtx as to mared kmp@;Ag r Cw ptets drawing on ro r.r <br />Sigma TIt�, y��?.✓ Data,w" <br />FOR DEPARTMIENT U" ONLY <br />Avpksuon Aoteptou tiny Bate Ansa . <br />Pit or riroatt frutyraCtion by flats Fintli Irk b1 (taut <br />Additional Cotrarrnti; <br />Applira»t - Return all copies to: 5nti Joaquin County Public Perr ttiSory eervicea �- <br />srsviroaawntal Health PermltJRervicea <br />445 N Sac Joaquin, P 0 Sox 9009, 9tka, CA 86903 <br />..y <br />PEfiMtTi>K1, <br />f-4 <br />z. <br />t3-24 IMV, +, as: <br />04 14x <br />fee <br />D"th <br />Pillar 141aterial t Depth <br />CASH AECEWED 9Y <br />OArt <br />TYPE Ott SEPTIC WORK: <br />PR <br />NEW INSTALLATION i I REPAMIADDSTION I I DESTW615TIrw <br />I INO swie system pet"wod it'table wawa' is <br />q►`` <br />Irwaliation vA sarve; <br />Residence <br />..-- Correnwcm ____ <br />Ottw <br />ave witffht X0 feat.I <br />Nurn1w of Avid' writs: <br />Number of bsdrooms <br />Charactw of WN to a depth of 3 lawt: <br />W <br />lA+ w table depth <br />SEPTIC TANK 0 TypelMfg CatJacity No, Contpar rants <br />PKG. TREATMENT PLT. <br />0 <br />Method of Dlttposal <br />Distance to nearest: Wall <br />Fouosabon <br />Property Lima <br />LEACHING LINE <br />0 <br />No. 3 Length at kws <br />Total kw4plsita <br />FILTER BEO 0 DistwM* to Avarest. well Foundati <br />