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APPLICATION <br /> SAN JOAgUIN COUNTY PUBLIC HEALTH <br /> ENVIHONYENTAL HEALTH 111191181 <br /> 445 N SAN JOAQUIN, PHONE (209)46 <br /> P O BOX 2009, 3TOCbTONI CA 95PO1 <br /> 0 -114 <br /> j��! ve T vt.A_R FBOI[ DATE ISSIIE2 ��., <br /> (Complete In 1-13—Cate) <br /> Applicatium is hereby eade.to Son Joaquin County for a permit to tno,truet sod/or instill the work herein deseof Tdehi^s <br /> Jsoallicatimquil isltY asidePublinHsalthi3arvirea. Ben Joaquin Cofnty Ordirfaace No. 549 and 1862 and the Rules sued Regulations <br /> c C ��� .�� /C Lot Size/Acreage <br /> �f���/G_ City <br /> ,lob Address <br /> Phone <br /> Owner's Name /`+-- �[1 n. - Address <br /> icenu N �'d'�' !�Phone <br /> i Address <br /> CwlfaClOr WELL REPLACEMENT (1 DESTRUCTION ❑ Out of Service ell <br /> NEW WELL ❑ SYSTEM REPAIR Q OTHER 0 Monitoring Yell Q <br /> TYPE OFA MP <br /> PUMP INSTALLATION O p15pOSAl FUO.— PROP. LINE <br /> IC TANK <br /> SEWER LINES PITS/SUMP$ <br /> DISTANCE TO NEAREST: SEPTAGRICULTURE WELL OTHER WELL <br /> FOUNDATION a Y <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CTION SPECIFICATIONS,- Disof WON Casing (�V <br /> p Opw eonom O Manteca TOut.ype <br /> of WaU Eacayation SW u V <br /> n industrial Q Tracy Type of Cadng------ d <br /> I Domestic/Privau Q Gf" Pack Ddu Depth of Grout Seal <br /> I'1 Public fl Other <br /> _Approx. Depth I I Esetem SuMw Ssel hutaNW by 1 <br /> 1 I litigationM.P. Sure Work Done. <br /> pair ......-arY'H� <br /> ReWork Done L3 Type o1 Pump �elin6 Material i Depth <br /> Well Destruct M Q Wall Dunster Filler Material It Depth <br /> Depth i <br /> TYPE OF SEPTIC WORK'. NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I 1 1Mili <br /> tetasation will verve: Residence-- Commercial Vlher D� TiG�Sc O4v/ <br /> Number of a.•ttg urtils: -- Number of bedrooms _ Water table depth <br /> Character Of VA to a depth of 3 feet: Capacity No. COrtlpertments <br /> SEPTIC TANK O Typs/11,1119 Method Of OWPOW <br /> PKG. TREATMENT PLT. QFoundation Property Lias <br /> Dlatartw to nearest Wall <br /> 7O �' Ian I - TOW la ohisir§ <br /> LEACHING LINE 140. a L6Agth a1 wm e ndaD°d- Property Lim <br /> nearest: . <br /> FILTER BED ❑ Distance to near : WW <br /> Number <br /> Depth pS1sa Line <br /> SEEPAGE PITS LI Distance 1 I Deto nee,": ViaFoundationProperty <br /> SUMPS <br /> and <br /> DISPOSAL PONDS Q <br /> tutu appkcatbn ab that tits work will be done la accordance with San Joaquin county prdmanws, slats wa, <br /> Ot tM work for which this perrryl Is waned.1"11 111 <br /> 1 MreDY Certify that 1 have the <br /> prepared Or f b-contr tktg ygnature <br /> rules and regulNioe of tM San Joaqutkt County setion laVua of CaUfann " Contracto(s hltafp retar�s cornP1l <br /> Horth owner or licensed agent's agnstura w,tfise the f011aw'mg- "'1 's COfity that in tM peA subject to work <br /> employ any Par subject to workman's hiCh m is"ued.i anaU amDIOY Persons <br /> sun in such menhir se to berame <br /> cartllise the loaowing: .11 wretr that in Dfe WOrms^ce of the woh 1M which this pertnt <br /> ton laws of California." Dau: —.i <br /> The <br /> ■OP OOM Corttppit reverse drawing pit side. - 7�yam- <br /> The 10911"nt must CNS ag)/¢rrrad _ <br /> iV" � !/ TitN: <br /> ----- <br /> Signed Z 1 <br /> FDA DEPARTMENT USE ONLY �. -7, Aran - <br /> Oan �.�.���� <br /> Das.�Jss-N" <br /> Application Accepted by Fiirnl Irnesa by <br /> Date <br /> Ph a Grout inspection DY <br /> Additional Cofmm~ts: S <br /> Applicant - Return all copies to: San Joe( County Public Health lees <br /> Baviroearatal Health pe9oatiser 19cka. 1 95201 <br /> `` sae O s.o Joaquin, ►Ef1MeTfsO. <br /> RECENED gY <br /> FEE AMOUNT DR-Nt.ri! <br /> H <br /> INFO JMau Malum <br /> EH ton <br />