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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC <br /> ' ENVIRONE[F.NTAL HIELTH AIx <br /> 445 N SAN JOAQUIN, PHONE ( tIR <br /> P 0 BOX 2009, STOCKTON, 5 01 <br /> PEUIT I 3 1 Y F M T <br /> (Complete in Tripli r a l <br /> Applieatiao in hereby tradeto Sep Joaquin County for a permit co construct and/or install the work herein described. This <br /> Applicatioo ie made In conFliance with Ban Joaquin county Ordinance No. 54 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Nealth Services. /,7/ q <br /> y- <br /> Job Address ^L-Y L.. F.L'1s:it _—,.�_�_ Cih hot Si ilei Acreryte /36.1! 3 �Z <br /> Ownsr's Nome71-4Mi--1 =w ADS Address Sft t� Phone ^arSS.i <br /> Conllactor r" V E_—ideate.- Address 7 Ao wWzL- Lriense No. C s-7G Phone -*144132-71 <br /> TYPE OF WELLI PUMP: NEW WELL ❑ WELL REPLACEMENT tl DESTRUCTION n Out of Bervice Well U <br /> PUMP INSTALLATION U SYSTEM REPAIR Cl OTHER C Monitoring Nell (} <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLU. PROP, UNE — <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> MNTFNDED USF TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C; Industrial G Open Bottom n Manteca Die. of Well Excavation_ Dia. Of Well Casing <br /> f.`Aonestk:/Private Ll Graver Pack n Tracy Type of Casing_ Specilicatoni <br /> iii Priblic ❑ Other Il Data Depth of Growl Seal Type of Grout <br /> I f Irrioatpr3 .._ Apprax. DOPlh i I Eastern Surface Seal Installed by <br /> Rapti,work Done U Type of Pump H.P. _ _.--r Stats Work Done — <br /> I Well Osaltuction U Wall Diameter $ean ag Material A Depth <br /> Depth Filler Material R Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REP.AIWADDR?ONX, DESTRUCTION I I INS aepnC Spslam Wall If prbkc Seurat is <br /> available within 200 al l <br /> 1 lnstaolion will serve: Residence Commercial_ Other—_— <br /> Numbav oh living unite —J.— Number of bedreomS_ '24 <br /> Character of sdl to a depth o1 3 fwt: SA x13 Warr table depth <br /> SEPTIC TANK d Type/Mfg4Caparity No. Compartments <br /> PKG. TREATMENT PLT-0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Um <br /> LEACHING LINE R"No. IL Length of lues .A -lee _ Total krlglh/alae r, ' <br /> FILTER BED CM Distance to nearest: WON lee' Foundan:nnProperty Lina lc- <br /> 1 SEEPAGE PMTS I 1 Depth --Si" NuMb&, <br /> SUMPS LI Distance to neared: Well Foundation Property Line <br /> DISPOSAL PONDS 13 <br /> 1 hereby cantly that 1 have prepared this apphica"n and'he'the work will be done in accordance with San Jpagrlin tWnry Ordinances, slaw Iowa, end <br /> rate$and eaguiatiow 01 rhe San Joaquin County <br /> HOMO owner or licensed agent's figrature cardiae the the loilowing: -11 ceHNy that In the performance of the work for which this permit is issued, I sheer not <br /> employ any person in Stith Mannar as w become Subject to workmen's compensation laws of Cddarma."Cgntwctbf't hiring or subr Onlrscting signature <br /> certifies the following:"I certify that in the podotNents o(fhe work for which this permit 14 issued,I shell OnVlay Pe0e0r4 Subject to workmen's cdmponsa <br /> tion lawn of CaIdomIS." <br /> The applicant mase"M for of radairad irrspsetionls/_Comprise driwino art revere side. <br /> Signed x". �L'�'+ Title: - - Dave: _/Z^ 2.- 9.3 <br /> ' ApplicFOR DEPARTM ENY USE ONLY <br /> Application Accepted by D61e ��r,,ryyyaala��� ,,y`..��v1119�3Area <br /> Pit or Grout Inspection by Data Final Inspection by �OILIu- fl 4( _ Data.l3�Iia <br /> 1 Additionsi Comments: <br /> Applicant - Return all copies to: San Joaquin Coun Ly Pua1Le Nealth Servicer <br /> Eoviroamentai Health permit/Servicers <br /> Brr �l <br /> 445 N San Joaquin, Y U ox 20091 Stkn, CA 95201 ysh1 b <br /> HED AMOUNT DUE AMOUNT R!t I TED C/A}SH RECEIVED By Q /P,},ERR7MITNO. <br /> En 13-24IAW Iris, , q ML{S S C V �L�HIr <br /> Et 1420 — <br />