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APPLICATION 14 SAN JOAQUIN COUNTY PUBLIC HEALTH SBItVIC$S PAYMENT SNVI$ONliBsiTAL HEALTH DIVISION 448 N SAN JOAQUIN, PHONB (349)46$-3420 RECEIVED P 0 BOX 2009, STOC11TON, CA 98201 JUN 15 SAN X)AQO;N touNYY (Complete in Triplicate) PUBLIC HFtLfilSE4VICes OfflRONMENTAI.MEALrN 01VISION Appllatioe is herebir OWA.to San Joaquin Cp>tV for a parent to construct and/or install the work herein described. This r applieatim to =WW in ooeiglliance with San Joaquin County Ordinance No. 569 and 1862 and the Rules and Regulations of San Josean County Public Health Sm"Ides. Job Address 1., ra a_ T _A_ A ve al I _ City T•rAi Lot Size/Acreage Owners Kane Address Phone Contraster ical edit/ Addressl So 'A w_ Marne, T.n_ #1A Ucenst No. 554 92a. Phone TYPE OF WEt.'tMRIP: NEW WELL C WELL REPLACEMENT n DESTRUCTION ❑ Out of rein* Sieh PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ Hooitorixtg flail DISTANCE TO NEAREST: SEPTIC TANK M.�.,;,_ SEWER LINES Sol DISPOSAL FLO, PROP. LINE _'20 FOUNDATION 2 n t AGRICULTURE WELL OTHER WELL PITS/SUMPS _.Flat a INT" fEI]USE TYPE OF WILL PfMLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Die. of Well Excavation tj Die. of Wall Casing n Dwmft/Private G Gravel Pack O Tracy Type of Casino PVC Specifications I'1 Public r - I'1 Other n Delta. Depth of Grout Seal 55 ` Type of ApoEtlang I I Irrigation _Approx. Depth 30 Eastern Surfau Saal Installed by.F111$$.. .Py Well f-aviwr Rewi+Wwk Dome ❑ Typo of Pump H.P. State Work Done_ wall Deswi c iott ❑ W44 Divmw famine Material ti Depth Monitor'ngDepth 7n t _ Piller 11aterial i Depth TYPE OF SEPTIC WORK: NEW INSYALLArtION 1 1_ EPAIR/ADDI ON I I DE TRUCTI I 1 oseptic system ted if public sewer is available within feet.I Msolistion will save: •Re6dence_ ComnteMW Other Number of W"writs: Number of bedrooms Character M call to a depth of 3 fest: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compsrmnnts PKG. TREATMENT PLT.❑ Madtod of Diapossl Distance to nearest: We* Faindation Property Line LEACHING LINE 0 No.i Length of lutes Total Nngth/size FILTER BED ❑ Distance to nearest: Won -Foundation Progeny Line S6EPAGE PITS I I Depth Bias Number SUMPS Ll Distance to nearest. Wall Foundation Property Lime DISPOSAL POO" ❑ I hoe*eisft vim I hm prepared this application and that the work will be done in accordance with San Joaquin county ordinances, elate Taws, and low end membelons of the San Joaquin Canty #fonts avow 4w licansed apartl'a aign"w*eerM m Mrsialf tvq. "I cartity Mtat in the psAortttance of the work for which this permit Is warted.1*0 not an►pioy and woofs in sueh eteNW as to becotrne atlbjact to woAmsn's eontpertsation taws of California."Contratloes hiring or sub oortsreelMtQ sipnatwe cerNat 04,feMJowwkW."I cwWy that in ole pefonnance of the wont for which this psm*is intrad.I shah employ Persons subiM to worltnt s eomparaa- don Iaws of Ifo mis" The appStsnt cions. Complete drawing on reverse side. Ti s: S+-A f f Com.01 0910 t Data: 911.1r,'401 EPARTMENT USE ONLY _Q ST 24'' AppNcaosrt Accepted by Data Areal PR or Grow!11 ep-i Ion •2`" �ftktal Inspection by Data 4-23.2 Additionri Cotrttnents. fiv, 6 Applicant - Return all copies to: San Joaquin County Public.Bealth services tlnrirosmenta.l Health Permit/Services 445 R San Joaquin, P O Boa 2009, Stka, CA 95201 PtjE ASAOUNT Lk1E AMOUNT Rtl#11TTtsD CASH RWOVID SY .. o1?E PERMIT mo. • iM ty741tlaf�.�/lel � �`� .rr'� � $�"�� I$� (/'��'� r Lr�L�J7�