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APPLICATION <br />SAN ,dill IN COUNTY PUBLIC HEALTH <br />�CESiTAL <br />HEALTH DIVISI <br />445 N SAN JOAQIIIN, PHONH {2i79�46 fJP O BOX �UOJ, STOCgTON, Cg 9521{Complete <br />/(*PEMIT....MPIRES <br />I YAM PRO,* DA <br />5 <br />in Triplicate)SanJoaquinCounty <br />Agpllcation is hereby <br />made, to far a permit isconstruct esndlarat1Qevi'th <br />application is evade in <br />COWli oY Seal <br />San Joaquin County Ordiriaace Eo. 5b9 anfl 1f3�2 and the Rules and ileguLCityrc4'"lEat <br />Joaquin County Public Health Servicesboas <br />Job Addrtrss <br />J. <br />t3lze/Acreage <br />Owner's Name ' +' <br />yC AddressPharu� <br />C <br />Ct tiratt <br />AddressJJ//>>�License Na.�����•�PhoneNEW <br />TYPE OF W£LLiPUMP; <br />ice hell <br />WELL C]WELL REPLACEMENT i"1 DESTRUCTION G tautofSeryTALLATiON <br />PUMP INS monitoring Well <br />DSYSTEM A£PAlR � OTHER i3ANKSEWER <br />DISTANCE TO NEAREST: SEPTIC T LINESDISPOSAL fLO. PROP.LINE <br />AGRICULTURE WELLOTPITSlSUMPS <br />INTENDED USE <br />TYPE OF WELL PRCONSTN SPECIfiCAT1ON5 <br />M Industrial <br />CJ Open Bottom C7 Manteca�ack <br />Cl Domestic/Private <br />Cl Gravel P [�l Tr Type of Casing_�.���Delta <br />i'i Public <br />Depth at Grout Seal`C�ragk <br />i i lrrioat+tus <br />I£astern SI.rlaea Seal Inst,alied by�A+H.P. <br />Repair Work Dans LJ <br />;_Ajppr6,X-07i;h <br />5tatae <br />uW� <br />Dostniction 0 <br />ttsa.ling Material <br />3 T�,tYI ZrH <br />Filler Material a Depth <br />TYPE Of SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I i DESTRUCTION I i (No saptic system pemitte <br />avlluiaisle within 200 feet.) <br />Instslation will serve: Residents I Comer <br />mcw that <br />Number of living units. _ I Number of bedr <br />Character of soil to s depth of 3 feet: Water table depth _ <br />SEPTIC TANKType/Mfq Capacity X00 No. Companments . <br />PKG. TREATMENT PLT, a Method of Doppssl <br />Distance to nearest: Well foundation Property Line _ <br />LEACHING LINE 06 No..& Le»gth of tints Total langthJ&iza � z <br />FILTER BED 0 Distance to nowtst: Wall 1 Z fouriastwn 240 Property Lists ,4-.49, <br />if public sawar <br />SEEPAGE PITS I I Depth __Li!Sire 9! 4 t Lf Number <br />SUMPS X Distance to nearest: Well - Foundation Property Lift 940 <br />DISPOSAL PONDS o <br />I hereby cenity that I have prepared this application and that the work will be done in accordance with Sats Joaquin county ordiniincas. state laws, and � <br />rules and rapuiatiara of the San Joaquin County <br />Homs owner or licensed aQsnt's signature certifies the tokowinp; "I certify that in the performance of the work for which the porrttait is issued. i &hall not <br />empty any person in such manner #s to become sub to workman's compensation UK" of California," Contractor's hiring or sub -contracting &aBnature <br />condi&& th Owr1, . "I CerrriY pe or of the work for which this permit is Issued. I shall employ persons subject to w wkmsn's compan". <br />tiaA Of C <br />The aspec t f f ed to drasn&'Ig nit r etas <br />y <br />Signed Title:. _ J... _ _ _ _.....�. _. _ Dalttl: I Z. - / S - 73 <br />I FOR DEPARTMENT USE ONLY na9 <br />Application Accepted by Data <br />Pit or Grout iAspettiitio by ata f�ai lottlpectior, � � _ �� Da <br />Additional Comments. <br />Applicant - Return all copies to: Saw JOAQuin County Public Health Services <br />Environmental Health Permit/Servicers <br />445 N San Joaquin, P 0 Box 2000 , Stkn, CA 95201 <br />FEE Ali40UNT WA AMOUNT REMITTED RECEIVED BY DATE PEAMrf'NO. <br />4 I+ 7 1 INFO o(CASH y <br />• Eh 1 <br />3-74 IREY, t1+ILI <br />EH (J'�'�� 1'w ✓� <br />ia-21 _.J <br />