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f 171,7 jv"A'e r ,l� ��`~ APPLICATION SAN 30AQUI1!1 COUNTY PUBLIC "AL #C>3S r� SN V i H(IINYBNTAL HEALTH D I V L �---- ' 4$-77' 445 N SAN JOAQUINr PHONE (209 �20 -77, 03 P O BOX 2009, STOCKTON r CA 1 ■"—� to a - 13D (ao , .13-% �(! (Complete in Tripliell )ANY# Anitestion is��tw t�Oa_to am Joaquin County for a peraut to construet sail 1�■ agaborlm- "plicatico is taade in eotpllence with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public S alth 8arrises. Job Address $$98 Schulte Rd_ city_ Irar-y slae/Aera.ze r Ownar'aName Lee Sustaire AddrasS8898 Schultp, Tram Phone A3.2..-ZS95 -- Contractor Hennings Bros. Address 3525 PelandSle. MOd.License No. 290813 Phone545-1185 TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENTWI DESTRUCTION R1 Out or service well Cl i PUMP INSTALLATION D SYSTEM REPAIR C) OTHER O Nooitorins Vail E� DISTANCE TO NEAREST. SEPTIC TANK i 0o t SEINER LINES DISPOSAL FLD. 10ti 1_fPAOP. LINE �_ FOUNDATION AGRICULTURE WELL OTHER WELL 50 t PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� Ll Industrial f]Open Bottom O Maniacs Dia. of Wali Excavation T��. mil.of Well Casing 00 00maS11CIPrivate CXGravd Pack L-ATracy Type of Casino-- PVC Specificationit I"I Public 1-1 Other (l Delta Depth of Grout Sall 10.01 Type of Orour R p fit nn i I o l� I I kripation __Approx. Depth I I Eastern Surface Seai Installed by dri„t..l,Q Repair Work Done Ll Type of Pump H.P. --i tate Work Dom wad Deauuction IX well Diameter �_ Sealing Material i Depth ' e n t•O n i t e • `TV\ i Depth Irl liar traterial A Depu Bentonite TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I IN*septic avatem p rmilted it public Nrea, is /1 i lost.) instWation will servemavtiiiable vrilftirt 200: Residence_ Commercial_ Other— T Number of Yving units: Number of bedrooms cf Character of soil to s depth of 9 Not: Water table depth hN SEPTIC TANK 0 Tvpa/Mfg Capacity No. Campartnwtte (� PKG. TREATMENT PLT.L1 Method of Diepoeal Distance to nearest: Well Foundation Property fine IEACHING LIRE ❑ No. ii Length at lines Total Mngth/alas f FILTER BED 0 Distance to nearest: Well Foundation Pr .— aperlY fine SEEPAGE PITS 1 I Depth Sire Number eft, SUMPS LI Distance to noarest: Well Foundation Property Line DISPOSAL PONDS 0 1 hereby terrify that I have prepared this application and that Ohs wok vAN be done in accordance with San Joaquin county ordinances.Stan favvs, slid 1 rules and regukuione of the San Joaquin county Horne owner or licensed agent's signatura osnifies the following: "I cattily that in the pariarmwKe of the work for vA*Ach this permit ki issued.I OW not en OOV any parson in such manner eS to bacons sublan to workn+ert'o compensation laws of California.”ContractarS hiring or sub•contrsctirtg signature cartifiss the following: "t certify that in the perlorrttane*of the work for which this permit Is issued,1 shad employ persons subject to workman's compenaa tion laws of Cstifornis." The applicant must cad for ail required inspPctiorq. Complete drawing on � ri signed x H e n n i Ilas�r n s_ 13 y �., Title: Dad: 8-3o-93 FOR DEPA ENT USE ONLY ApplicationAccepted byC:UA Data Arae ,. 1 Pk m Grout inapsclion by r Dale Final Inspection by fl,� a Dna.47o�a W�) Addhiondl Corntrants: M rAAL1 .a A Applicant - Retu all Copies to: Sao Joaqu2R County Public Health 8ervice �i Borironatental Health Permit/Service 'N �� a �a N ff 445 11 Ban Joaquin, P 0 Box 2000, BLka, CA 1 ilr]–�p�a '� r /Q INFO AMOUNT DUE AMOUNT REMITTEO RECEIVED aY OA i4mil-No, D T it412}24laiv,%IN%I Ae r J r u+16 1111 / . _ 00 3y-)6