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t .> <br /> r <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC IiE.ALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (205)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT I:RPIRFS 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> j, Application Sa hereby Bade to San Joequln County fur a permit to construct end/or inatall the vorx hereln described. This <br /> application 1e aade in coesp1lance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules wA Reguletlons of Sen <br /> Joaquin County <br /> = �Pubbl�ii7c�Nof�l. S'eryvi�c�es Li-. 51 xe/Ac rengc a <br /> Job Addresspry <br /> � <br /> Owner'.Nome f"f/ dresS Phone _.--F-Jr_-L.c <br /> -r- <br /> N <br /> Conlracto,_ S4_47�L_. cn5e N6. PI10ne <br /> TYPE OF WELCIPUMP NEW WELL 11 WELL REPLACEMENT DESTRUCTION ;-1 Out of Service Well G <br /> PUMP bVSTALLATION 0 SYSTEM REPAIR OTHER G Wonitorlrg Well [I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __—— DISPOSAL rLD.-_._ PROP. LINE — <br /> FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONST? , TION S,­iFICAT!ONS <br /> oi -v 0 Industrial 0 Open Bottom 1-1 Manteca Die of Wall Excavation Do.al Wall Casing _ <br /> N Domestic/Private 0 Growl Pack Ll Tracy Yypa o1 Calling___.... Speuficatwns_ <br /> I.1 Pubw- Il Other Il Delta Depth of Grout Seal _ Type of Grout <br /> I I litigation -_Aplvo+. Depth I I Eastern Surface Seel Instilled by <br /> Repiw Work Dais U Type of Pump H P. State Work Ocre-... <br /> West oastruc:ion O Weil Diameter iiealfng Material L Depth <br /> Depth__-�.r/Tiller Naterlal A RDth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION 7r REPAIWADDITION i I DESTROCTION I i INo wptic system permdted A public wwcr is <br /> avauaGle within 200 leet.l � ` 1 <br /> InstallationwiM so": R dente Co, other._ � CU►-w�Arr Y �\t 3 �'0 r t,ac> <br /> inn r <br /> Numtw 'A Yvv+g units: 11 .pe a 1- <br /> Ch*wotar of sol to o depth of _'vVatar able depth_ <br /> St"TIC TANK 0 Ty; I_. Capacity: .06.6 No. Compartment. <br /> PKG. TREATMENT PLT.Q Method of Disposal <br /> Wall 4Z-{[_(,f Foundatwn Protkny Line <br /> •,`;1_=•• LEACHIN3 LIN! No.1 Length of lines _ _s..c Tn,al leng(hl.to <br /> `FILTER BED Distance to nssrest: tNeu jQ Founuat on Piopertl-Line_;'_. <br /> y'r SEEPAGE PITS 1 Depth 4b Sue N moors <br /> Skimps LI Distance to nearest: Weal� FovndniGn .� Proporty Line _ 1 <br /> DISPOSAL PONDS 0 _ <br /> I hereby CMt/11r that 1 have PrsparwJ this►ppi•cation and that the)wait,will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rule6 tats repuNtlons of the Son Joaquin County <br /> Ilams 7wner or licen6ad*pent•&signature certiLss the foLowtng:"I candy that in the performance at the work for which this porrrvl is twitsd,I"If nor <br /> employ any person in such manner as to became subject to workman's compenaot cn laws of Clldornia."Contractor's hiring or sub-COntraChng signature <br /> owssis the folovwq:"I certify that in the peAamsncs of the work to,whicr this permit rs owed.I amu employ parsans subject to workman's campanile <br /> tioo fewa of Co4fom4." <br /> This appYcsM m I Call for M n ed W, b s.Complete die on r�w,s-rse^aide. •tom, <br /> SiWed - t. itis:-.C..�,at ---- -- Dete: <br /> •?%t f� FOR ARTMENT USE ONLY <br /> l-V(� / -7 <br /> .•� 1 .iy�.. Data � Ares 1? t�. <br /> tion Accepted by .•}� �[.�/� - <br /> ..�, t Grout Inwpe;von by cinsi tnaWction by Do'. =t.� <br /> i.ddhional Com meets: <br /> Applicant - Returo all copies tn: San Joaquin County b11C Health Services <br /> 4 ., Pavlronaiental Roalth Perslt/Services <br /> 4J5 N San Joaquin, P V Box 2009, Stkn, CA 95201 <br /> sEEAA10a1NT DUE A4aOVNT REMrTTED K RECEIVED 2Y DATE PCRMn NO <br /> INfO CASH <br /> I>E.IAW.t,.,i <br /> 14.36 -- <br />