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,I: APPLICATION FOR PfiRUIT <br /> SAN J{ -.'jim CvuNTY PtTBLIC HBALTH ST' ICES <br /> 411- RONIMTAL HSALTH D I V I S f <br /> 445 N SAN :JOAQVINi ;.PHON$ (2p9}408 3420 <br /> P O BOX 2009, STOCKTON; "CA x95201 �.; t APR 1 3 1993 <br /> Y <br /> TH <br /> (Complete itis Triplid1ate) ,_£ ENVppIRFF�OAANMf!EN ALAL <br /> tiai work <br /> bLr1^�i41�F1 �J7riA <br /> This <br /> Application is berebir sande to San!Jotquid Couatuiriora pe 0 dritilt t�irit�t b4i No. $49 ind l�e�thAe�ea e� Regulations of Sea <br /> application is hada is coii+pitante with 8ati}Joaq T q <br /> Joaquin county Publialiesath 8e1i106s. <br /> 1.ot Site/Acreage /3-.Q Cie.. . <br /> N Ibd: -Stu pit^ c�tv �/ <br /> Job Address /"L,OQ S'r+rli 7ti7 i �4ti 3/089 F i <br /> ; I �iV/7- Phone rM rK <br /> Owner's Name Addrisf <br /> iV Q n Address .d 3 �C 0 v ICense No.. <br /> Centracta <br /> TYPE OF-WELL/PUMP' i � NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ W, oT 8erviee Well ❑ <br /> I,PUMP INSTALtkII�ON 13 <br /> SY$tE1N I'tEPAIA �.e TH A O t4onitoring Ve11 C3DISTANCE TO NEAREST SEPTIC TANK _ SEWEA LINES [:� : DISPOSAL PLPROP. LINE. ,PITSlSUf,�PS ..._. <br /> „FOUNDATION zZ,S AGRICULTUAE WEL•t �N//}' OtHEA MLL <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONStRlJCl1ON SPECIFICATIONS ' <br /> bit.:o1 Well 60" i <br /> Cl Industrial ❑ Open Bonar D Manteca Dia: of thlefi E>itavation >y <br /> Type at"6641A <br /> S + a C Spicilic>rtibn>t <br /> E.1 Domestic!Prlvata ;;Gl Gravel Nek C7 Tracy 4- <br /> I'i Pr�bEic r¢ �`.Q1:Othii El Delta t bth al Groin 96N `Ttipi of Grout <br /> L�IMr; <br /> 1 I (rripelion {��Appro><: t)epth -, 1 I Eairfrh ,. ;, Surficfl Seel Installed <br /> i Stab Work Done <br /> Repair Work Done U ;j��type 61 Pump <br /> k Bsing 1litlriel + De`pth <br /> Wag DestnKlion D I, Wetl Diantetsr - u • <br /> I'.Oipth )i11er lfaterial i !}egth r� ; <br /> TYPE OF SEPTIC WORK.. NEW INSTALLATION I 1 REPAIR/AODITION I If OESTRUCT11 I I INo septic system pirmilted 11 public lower is <br /> " evtiilable within 2W-fall.I <br /> Installation viAM Ntve �;giijdencli_ Co,i;;r►arClal .__. Other -=Y t <br /> ?4u.&& Of t3rr"UAW dumber of bidroomtt <br /> Character o!M4 to J of of 3 Isiti{ p f k Water table dsp'th- 1 <br /> SEPTIC TANIf. ;�j[l Type/Mfq Cipirtity_ Na. Canpanrrtanti <br /> PKG. TREATMENT PLT.'Q fix: Mithod of bisposal " <br /> Pr no <br /> A. <br /> DistanCi t0 ttailnist: Weila,ndetbrin1i ro <br /> - <br /> r.. <br /> LEACHING LINE 'CI No. S Lei oath of lirtei y To sl iingth! <br /> ` Ofo Line Y� <br /> FILTER SO 0 Distend* i6 64seit: Well Fbundatlon - pittY <br /> E, ,I t ' <br /> Ilki , <br /> SEEPAGE PITS I I Dipth Sitti NuMbef <br /> SUMPS f ;LI Distend to maria*:, . . Wiq . ounda <br /> Ftion .� Propany Lini ,. <br /> DISPOSAL PONDS . ' a10 <br /> I hereby gently that I hs"vi prepared thh igplkation and that thi work will ba.`done in accofdencO with San Joaquin county,ordinance*,itete laws, end <br /> rules snd reguillia iY bf IM Sen Joaquin Ciyuiitr x: <br /> Homa owrwr tai lkartsa�'Ppaht a!W*nstilfi eirtiflis the folowino: "!cirnity thi f In thi piirforinanra 61*4 Werk 10i which thii pirtnit is issued,I shalt not `h <br /> ampby any Mott in wtt;M"nat is to 611cerrw subiaet to wotkman's compehsition I&*Ii of Ctillfornia."CbAlricidies hiring of sub•contractinp sipnsture <br /> ,. <br /> eanifias the Mom*7VOl tify that hi IN pet[ornianei of the work for which this psrrnit is itiaued,1 shall irtiploy parions ilubjict to Workman's t�mpanra ; <br /> tion lawn of Callfofnli"''ra �' o <br /> Thi appMcent situs* N f su uirid M4pittlons. Com drawing on reverse / L y <br /> Signed Title: r 0 r 1-rr Difs: <br /> h FOl1 DEPAgTMEfIiT USE ONLY /.r <br /> F <br /> Application Actiptod by =r Data <br /> Ph Ilt f)ltltit IflllpaCtiOn lay 17ite :;.�� F16010OWWrl by bit's _ f <br /> Additlorwl Canimant►: <br /> - <br /> Applicant - Return:Lll copiea .to: Sari Joaquin County ftblic Health 5eirvicee �at! <br /> >trivironmentsl HAalt1) 0 9Mit/9ervic9b <br /> ;.. ` 4i 445 N "San Joaquih; P O Box 2009, Stith" CA 95261 <br /> FEE WAMOUNT otill `AMOUNT AWITTEDCASH RECEIVEo EY DAff R 'NO. <br /> INFO V 7 <br /> EM sift IRsv.liest $� ZL <br /> Z�Z!a �� 7.2 ' <br /> _ ,h d <br />