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APPLICATION FOR PSRNIT <br /> SAN JOAQUIN COUNTY PUBLIC - <br /> SNYIRONNEKTAL HEALTHDI IS <br /> 445 N SAN JOAQUIN, PHONE ITS <br /> P 0 BOX 2'009, STOCKTON, zo <br /> (Complete in Triplica ff.. <br /> Application In hereby mde.te fila Joaquin County ror a permit to construr:t, ofi <br /> applieatioo-la,nsde in casoUance with fats Joaquin County 0'" name No. 549 oar of Ilan <br /> Jcagmiu County Public Health Sa ces. ,�/�+t, �1 h <br /> .fob Address �c t�L� r t`u r Cit Lot Sine/Acreage � !V Q�+� <br /> Owners Nome — `7 Address �, ? Phone 1-4921-11,77 <br /> r / r <br /> Contract Address&So 7Z 7 License No. ?K Z(, Phone 3b b gra <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Q Out of Bery to all <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Van ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FED. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITVSUMPS _ <br /> IINTENDED uSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 industrial a Open om 0 Maniacs Dir. of WA Excavation Dia.of Wed Gsw <br /> i17.1 Oornestic/Private Cl Gravel Pack A Tracy Type of Casing_ Specificatiolm <br /> I'1 Punic t'7 Qttlar n Delta Depth of Grout Seal Type of G"M <br /> I 1 1160atlon r Approx. Oepth I I Easletm Surface Seel Installed by <br /> Rap&Work Daae U Type of Pump H.P. Stare Work Done, <br /> Welt Destruction 0 Wei Diameter Sealing Material A Depth <br />` Depth filler lletarial A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADotT10N 1 I DESTRUCTION I I INc septic syatam fitted 4 public iewar is <br /> available within 200 leeti <br /> Installation will anew; Roaidence�Comrnercisi_ Other <br /> Number of living urtks:__I— Nuanbe►of <br /> 12. jot- <br /> Chwectv of alto a depth of 3 Mat: Water tam depth <br /> szi; <br /> SEPTIC TANK Typal Mfg r Capacity No. campaeterlartta <br /> PKG. TREATMENT PLT.Q Method of flis�osal <br /> r, Distance to natirat: Wall >�'T Foundation. Property L6-a •S�,.. <br /> LEACHING UNE No.A Length of lime Total langthisits p <br /> FILTER SED 0 Dietanto to nwoat: Wap tis Foundation__Aa 4-L ,- Preparty Una <br /> H <br /> SEEPAGE PITS I Depth Size N�lmbar <br /> SUMPS LI Distance to merest: Wall 40a Foetredation - Proparty line <br /> '• DISPOSAL PONDS - 0 <br /> 1 heratry certify that I have prepared this application and that the work will be done in accardonee with San Joaquin county ordinances,state lawn„and <br /> rules dad reguletions of the San Joaquin Cotttl%Y <br /> Homs owner or ficenead agam's signature cartiria tha f vk;winp: "I cettity that In the performance of the worts for which thin pormit Is Issued.I"not <br /> amplov env person in such manner as tc bacons subject to workman's eompatteation Iowa of Caiifomia."Contractor's hiring or sub-aorttraeft signature <br /> certifies the f okwAng:"I comity that in the palomrancs of the work for which this permit is issued,I shah employ poreona subject to workman's conepsnsa- <br /> tion laws of CaMonats." <br /> The spplimm and for i Impactions. Comptate drawing at reverse aldeA ay_ <br /> sign" TIUs t+e P _ . Data: <br /> FOR DEPARTMIENT USE ONLY <br /> Application Accepted by D4itt1 �" Ares . <br /> ZPor Grout Insspeecctiifo��n by Data Final Irtspectlon by_r Eiaos� <br /> Addldcoa'peinan+ tt !!'Y <br /> Applicant - Return 211 .--lee to: San Ja"cin Cottttt? public Health services 01t <br /> 131kviroaueatal health Permit/t3ervicae <br /> 1// I 448 M San Joaquin01.. 2006, Atka, CA 8 O <br /> 4�i Z_( 1 11 F AMOUNT DUE AMOUNT REaiI�EG rttCEIVEo 111VY a►YE PEgnti?"ND. <br /> INFO <br /> i . t:N tsx�Ilrev.trssa � lag— <br /> rN iN>t <br />