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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH Simi <br /> • ENVIRONMENTAL HEALTH DIVI OW(T <br /> 445 N SAN JOAQUIN, PHONE (2 9) 0 <br /> P O BOX 2009, STOCKTON, C9 J <br /> �2r <br /> (Complete in Triplicat )INV <br /> Applieatim is hereby made W Sas Joaquin County for a permit to construct an rYY Le in dawn <br /> 4pp21oatim 15 rale in 011"00 with Ban Joaquin County Ordinmce Bo. 549 ane 1862 not or Bun <br /> Jt>egula County Pw31c Health Services. <br /> Job Address �- / 6 .'19 N*6 WA141- ,,y5Teefi'Ti.1V Lot Biu/Acre►Se !tL'b•!G>e' <br /> owners Nerne I- eoy,#J d Yr ex>A A ldrar S,taft Phone <br /> 0.Contractor d Address 0k ✓ata O License No.'VV# / Phare <br /> TYPE OF WELUPLIMP: NEW WELL [3 WELL REPLACEMENT Cl DESTRUCTION ❑ Out Of Beryiee Fell <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 6 Monitoring Wail ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PRS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ <br /> Cl IndntrtM ❑ Open 801101", 6 Manteca Dia, of Weft E.cevation_ Dia. of WOE Caning <br /> 171 Dorrrsdp4PrWata 6 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public n Other n Delta Dspth.of Grout Seal Type of Grout_ <br /> I I Irnigriat _Appro.. Depth I I Eastern Surface Said Inataasd by <br /> Repair Were Dona U Type of Pump H.P. - State Mork Done <br /> W4M Destruction ❑ Wea Dianlre 84111AS Material E Depth <br /> Dpth Tiller Ikterlal If, Depth' . <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION 1,1 REPAIRIAOOiTION do DESTRUCTION 111No septic system prmhted it pubic saws,is <br /> • "actable within 1D0 toot.) <br /> Instatnion"serve: Ros4oncs L Commerciet_ Other_r \ <br /> Nurnoer of rWmv units:�_ Number of bodrogms E. ' <br /> Chrocfr of ase so a depth of 3 feet: G G Ay+ Wotr table depth « ! <br /> SEPTIC TANK. U TYpe1M1g Capacity No.Compartments <br /> PKG. TREATMENT PLT.❑ a Method of Disposal <br /> Distance to noween: Wei Foundation_ Orop" Line <br /> LEACHING LINE Qr No. 6 Length of tries S''O r Total lengthier dowr1O4� <br /> FILTER BED ❑ DisWtca to heartier: Well _ Foundation yTT _ PropTly L" 99' (� <br /> SEEPAGE PITS yr Depth %L-f' Sue- ,'L diA Number f <br /> SUMPS LI Dutrtce to rw est: Wore -100' 'Foundation Property Lir, 900 <br /> DISPOSAL PONOS p <br /> I hreby comfy that I have prepared this application rd that the work wl.(.bs done in ecu deme wnh�ri Joagwn county Wd rui t". nae laws, ata/ <br /> rYlea Mrd repuabo s of the San Jisawn County <br /> Hamra owner or Ikrwd agmfs eipne"a eartirse the following:"k certify the(in the performance of the work fa which due permit is issued,1 shelf nor <br /> OfWW shy Preop M such rfkw~as to become subject to workmen's compenathon laws of Co fforfus Conuacta's hiring or suDmntractiq elgnatu s <br /> cenirss the i gI ca/tify toot in the fletormance of Ilia wofk for which this permit is eaued,I eh4M srploy pareses suboict to workmen's eompenae- <br /> Son laws of Garorrp .. . <br /> The apykrn�for alb#04-411 kAWtiom. Completo drawing on,nurse aide. <br /> Signal Tits: Do,: 161HSV—V <br /> FOR DEPARTMENT USE ONLY <br /> Appicati Accol by ` Date roo _y <br /> trt} <br /> ��hsp4ttbn by Dais .. j , Final Impaction by Data /r <br /> r'ottmtnnu: <br /> Applicant - Return all copies to: Hao Joaquin Counts public Health Services <br /> \\ Environmental Health perait/service, <br /> "V 145 R Sea Joaquin, p O Bo: 4008, Btkm, CA 8 01 S �)11485 <br /> FEEAMOUNT DUE AMOUNT A ITTED <br /> CASH RECENED ay .DATE <br /> �t <br /> . hl sial leN.rr.ei <br /> W 1476 f ` u J <br />