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13 -a".( 3 <br />jR # AN JO) <br />ID # <br />FAC # <br />APPLICATION <br />ZUIN COUNTY PUBLIC HEALTH MVICES <br />1VIRONV$NTAL HEALTH DIVISXON <br />CE, Vic ftF164i <br />SAN JOA UIN PHONE 209)468--9420 17 <br />BOX 2009, STOCKTON, CA 9520 1�UyRl� DEC � <br />- IRE Y FAQM D u P� %A, TAL j irA <br />LIH <br />INV # _.�� 1 3 � (Complete iD Triplicate) S�R�'ckS <br />County for a perralt to construct and/or .install the York herein oescrAbed. This <br />application is mtde in compliance with San Joaquin County Ordinance No. 549 and 1962 &nd the Rules aad Regulations of San <br />Josquin County Public Health S1er <br />Cjvices. 1 `(� l [ }, , <br />Job Address 6 C( {i �`-1� frtil ��Y .. z Gry .3%�k� Lot Sine/Acreage b� 4,6 --- <br />Owner's Name _it Address _ _ _�._._ _ --- - Phone Y3� g241 <br />Licerlsl�Ne. <br />TYPE OF WELLIPUMP <Q£ WELL 0 WELL REPLACEMENT 7 DESTRUCTION 0 Out of Service Well Cl <br />PUMP INSTALLATION U SYSTEM REPAIR 01 OTHER Q Monitoring Well <br />DISTANCE TO NEAREST; SEPTIC TANK _ SEWER LINES DISPOSAL PROP, LINE <br />FOUND IQN AGRICULTURE WELL OTHER WELT PITS/SUMPS <br />INTENDED USE 'EYPF VIIELL flR09LEM AREA CONSTRUCTION SPECIFICATIONS ^� <br />i_) Industrial O n aoltam Manteca Die. of Well Excavation ti rf.*" . of Well Casing <br />(A pomesticJPrivate s� Pack Ll Totcy Type of Casing__� `+ � d ications-- --- - - <br />I'I Public ^vetr[ f7 Decca Depth of Grout Sea! tout <br />I I Irrrpauon 4r4LSZC Depth I I Eastern Sa.rtace Seal Installed by <br />Repair Work Done IV&NN ump H.F. _� r State Work Oona �. <br />Well Destrucliki. iameler Sea -ling Mtaterial i Depth <br />h 1W 7e <br />Piller Material it Depth <br />TYPE OF SFr' fiK, EW INSTALLATION I i REPAIRIADOIT IDH 1 OESTRUCTION I ! (No septic system par"pr r is� <br />i available within 2W toot.) ' <br />Insta"aiiQ►t Residence —X- Commercial — Othar j�j0r <br />Num tTvr,,�� ns: __1_._ Number of bedrooms Tr{ <br />Ch� Of 1glDto a depth of 3 teat: Water fable depth d <br />SE `Al I& Type/Mfg"` �f�`L�_ _ Capacity �`�f=d No. Compartments �- <br />i�C TREAT ENT PLT. C1 tX f yt rh Method of Disposal Cc <br />Distance to nearest_ Well ri O Foundation Property Line - <br />All <br />LEACHING UNE > No. b Length of lines ,J ���nl / Total length/size Z' �^ 2 <br />FILTER BED n Distance to nearsst: Well. _ � 4 f Founaatlon L �Property Line r <br />SEE9GE PITS Depth _.2,C Siete Number _ <br />SUMPS i.l Distance to txurrest: Well Foundation . ^. Property Line <br />DISPOSAL PONDS C <br />11 <br />I hereby certify that I have prepared thin apphcation and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br />rules and repulsbone of the San Joeouin County <br />Homo owner of licensed agents signature tortifies the fottowing: "I certify that in the performance of the wpr wicA tftiiLpArryit is issued, l shale not <br />erttWrty any perttpn in such mannan as to become subject to workman's compensation laws of Cafifor . oniractor's hiring or sub -co signature <br />certifies the foilowing: "I certify that in the performance of the work for which this permit is issue shah employ persons subiecr to workman's c nsa- <br />tion aaws of t must is." � ry a C � � % 3 <br />The applicant must call for Al re4uir j� ur Mons omptnte Urswing an reverse side. l.�J <br />Signed Title:6ate: — hi I <br />FOR DEPARTMENT USE ONLY <br />Applieerlon ACceptatl by d, Date ID /I �� Area <br />Pit or Grout knspection by Oats Final Inspection by 4,/f / Date -41 <br />AdditloneliComments: r4 ,+' At .7LL/J �' <br />Applicant. - Return all +:opiers to;Jtzn Joaquin County Public Ftea[Ch Services <br />Ravironmental Health Permit/Services - J�6t �' ✓r�' <br />(� l( 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br />EN 15-74 rl1EY. K e. <br />EM tc,1e <br />FEE <br />INFO <br />AMOUNT OCE <br />AMOUNT AEMtTTED <br />ASH RECEtveq 19Y <br />DATE <br />PERMIT' NO. <br />