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APPL I CATION FOR Itl! I T
<br /> p� SAN JOAQUIN COUNTY PUBLIC: HEALTH SERVICES
<br /> ENVIRONMENTAL. 11EALTII Il I V I S I ON
<br /> > rS6B
<br /> -34.20
<br /> 1601
<br /> E. HAZF,L1'ON AVE. ,
<br /> i ifONE (?.09)
<br /> P O Box 2009, STOCKI'ON, CA 95201
<br /> P +JAL ;Iia 1 YE H 1 �
<br /> (Complete in Triplicate)
<br /> Application is hereby made to San .:oequin county for a permit t� construct ard!cr 'r.+:al] the vork hereln descrlbrtd. This
<br /> application is made ir. compliance With San Joaquln County Ordinance No. `,!9 and 1862 and the Pules and Regulations of Sen
<br /> Joaquin C^unty Publi Health Services.
<br /> y
<br /> Job Address _ 0,�_,Q 916 Isj
<br /> /1� i /�til� '_ Add,-!,s
<br /> Owner's Name ��t�----- -�
<br /> I S t„yre�s' V-_/-Aye/ � L :i•'sP nry]7?ars _r--P^o^�`3 3y y7 ..
<br /> CPfltl Jt:11N r__„�_�.r�!5,��.5...�-.___-_'A• _ '�'�!J"._...���....__..._.�.____-
<br /> E OF WELLIPUMP: NEW WELL WELL PEPLACEP"EI.IT DESTRUCTION 4�Out M Service well 0TYP
<br /> _ Monitoring Well E�
<br /> PUMP INSTALLATION 9r SYSTEM REPAtrl " OTHER
<br /> L DISP05AL PLD. - PROP. LINE
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES —_—_
<br /> FOUNDATION AGRICULTURE WELL _ OTI'+ER WELL PITS/SUMPS
<br /> INTENDED USE TYPE OF WELL PROBLEM AR_EA CONSTRUCTtD_N SPECIFICATIONS—
<br /> } I1
<br /> Industrial C Open Bottom i.; Manteca Dia of Well E.cavatlnn Ora. of:+yell Casing ..Y—.
<br /> � Type of Cawrt _�_-_ _ Spenhcatwrs �
<br /> `J✓Do�+estic�PriWate >1 Gravel Pack l'i TrAcy J -- /^
<br /> I'I Public I l Other 1 1 pelta Depth of Grout Seal ,.SO - Type of G:out„ye_
<br /> I I Inr{gatv.n 7SJ_Appxos. Depth I I Eastern Surface Sool Installed by4`OS-A :7%'w -
<br /> Repair Work Dane 0 Type of Pump S H P, _f 0 State Work Done_ Cr
<br /> Sealing Matertal A Depth _ _
<br /> Well Destruction 0 Well Diameter D
<br /> Depth ,. _ Filler Naterial 1 DePth D
<br /> TYPE OF SEPTIC WORK: NEW 1N5 rALLATION I { RE.9AIAiADDITION! C)F.STHUCTION I I (No%epnC %y%I"m permirfed.I pvhl.0 sawef r%
<br /> available wilb'n 200 feet.)
<br /> Instsllb6on will nerve; Residence.-__ Comme*tial _,-_ Other
<br /> Number of living units: Numbs,of bed-ooms---
<br /> is
<br /> Character of 800to a depth of 3 feet: Water tables depth
<br /> SEPTIC TANK Cl Type/Mfg _ _.__--._ Capac,ty__,___,—__ No. Compartments
<br /> PKG. TREATMENT PLT,n Method of Disposal
<br /> Distance in neeresr WtH --_.�._..�..- roundat.on P,nperiv Line _
<br /> LEACHING LINE Cl No.8 Length of lines -_-
<br /> FILTER BED Cl Distance to newest: Property Lena
<br /> SEEPAGE PITS 11 Depth Size
<br /> SUMPS L: Distance to+Merest-. Well .___ Founds nn _�, �._ P:ooenv Line
<br /> DISPOSAL PONDS Cf _
<br /> I hereby certify that I have prepared thio applicauon and That the wO,t -It La do'v'^ a:ca•d.,h.e wr1', ja"Jceau'n county wd'nances- state taw%, end �1
<br /> I- rules and ragutarion%of the Sen Joaquin County `JLC/-Jr-_
<br /> f Home owner or licensed agent's signature teml-es the fonowanp "1 candy lhes !:,the t:e�L'�".i',tie of:hl wu,k for Ahich this phrm.t is-sued• I she!I not,
<br /> employ any person in au:h manner as to become suhlect IO_oAman's;ompensut-^n t..,j rf Ca..'Orn.a" Coit,ictoe'S hr+,np or%uthcantracnng Signaiuie
<br /> certifies the following-"I cert+fy that in the performance of the W71,to a.ratoy persona subject to workman's compensa- ,
<br /> lion laws of California.".
<br /> F- The applicant must call frr aFt r used rnspechons;Cumplete d,".rg n,, rr,.Arse s-c,� Y7
<br /> 4` Signed X A --- Title. _V.__L.NC�__.�.__I"----- -. _.._._._-»-.._ Date: ------
<br /> I FOR DEPARTMENT USE ONLY /^f
<br /> Avpl"trprl Acceoted by - '}- �- -�� ..�.-� Date_.-7__._�-� /. Area
<br /> I --
<br /> Pit or Grout Inspection by�-' .....�. Dato �.._u. {,^n;i�eoe;t or nk ..r �l.�L�--"-•�� D�tt,r-�J�.._:
<br /> Addit'or,t Comments: �w �_ _ _—.._� -�_ __- --- ---- 7--
<br /> Applicsnt - Return all copies to: Sw! Jtxq"Iu Ccunty
<br /> ! Sentc+e, Envtrwinentn' i!.al:'.. Pri-a.t,'_.-r�•:;-+ '{}`�\�]
<br /> i7 ]br`• E. Hnt!Itrn Ave.. F J ?hex '0". 5tor.zter.,
<br /> jj rtt AkAIOU-4T blit AMOUNT"T%0 .`tn � F.�lf1 I 'r:�f{�P♦ j !�AtL I'EnMlr tie) !
<br /> I kw['�tRtY , " � 1 ✓ e�_.. _��_".�.'._-.....r����!�S./ _ ��1:�.,..._-. -_"�y�� •�� l���5}1�1 j
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