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AH—'JAB WED 1J:IJ ({E•[M1r.MJLN]b l;ubU IA1 rNA ilu, sib Jbe dl3ii r Ucruc <br /> APPLICATION <br /> SAN JOAQUiN COi1NTY PIMLIrC II1;_.AI.TH SERVICES <br /> ENVIROMWENTAL REAI.,TH DIVISION <br /> 446 N SAN JOAQUIN, PRONE (209)468-3420 <br /> Y 0 BOX 2009, MCKTON, CA 95201 <br /> PERMIT MIRES 1 YE" FROM ELATE ISSUED <br /> (CompieLe is Triplicate) <br /> Ayplica.U= is hereby made to San Joaquln County ror a permlt to ccastruct and/or 1111ita11 the work herein described. Thi,, <br /> sypltcatiou In mads in compliance with Bar Joaquin County Ordinance No. 541 sad 1862 and the flulcl; and Rezulatiors of San <br /> Jcaquiu Cvuaty Public health 3errlcen. <br /> ,fab AddrM 212 W. Pine SLrePr City (.i7di Lot Size/Acrrage -_ <br /> I <br /> ,0,,W's Noma RPPIrman Capj t•nl rnrT Address .—P.f1� 139 G Z � s 1.8� �A Phone _ <br /> Trdpsglobal Euvirunmearal Rancho Cordova <br /> Contractor Geochenlistnd: Address 11350Moitlpr Park PlaraLicanseNo.--7DA5AS—Phone(9ljj .J_ <br /> Tl&E OF WELL/?UMP. NEW WELL ❑ WELL REPLACEMENT i UESIRUCTION Ll Out of Service Nell �1 <br /> PUMP INSTALLATION L' SYSTEM REPAIR G (ITHER :0 st&p1 t oTAWe1,1 � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_ PITSlSUMPS <br /> INTENDED USE TYK OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial O Open Bottom u Manteca ".of Weil Excavation 1-i nrh Dia. of Wel!Casing <br /> I'. Dumestic/Private u Gant Pack 0 Tracy Type of Casing- Specifications <br /> i-I Public 1I Omer n Dvita Depth of Grout Seal Type Of Grout_- _ <br /> I d liriparinn _AprvoK. Depth 1 I bastern Sr.rfaey 6e4 InaWiod by <br /> Aapeir Work Done u Type pt Pump _ N.P. Stata Work Done , <br /> Wed Desoucuon 0 Well Diameter Sce.1ing Katerlsl i Depth ^ <br /> Depth 'Piller Katertal g Depth Tlpnh to <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 71 REPAIWA00171M4 1 1 DESTRUCTION I i INo septic system permitted if public Sdwer is <br /> avarla4le within 2W feat.) ti <br /> Invallahon will serve: Hersidence_ Commercial_ Othar t <br /> Numb.r of living units: Number of badroorns <br /> Character of soil to a depth of 3 foot _ Water table depth <br /> SEPTIC TANK Q Type/Mfg Capacity___- No. Compartment: <br /> PKG. TREATMENT PLT.0 Method of nispvsal <br /> Disunco to noarast. Well Poundation Property Lina <br /> LEACHING LINE Cl No. & Length of lines Total Length/size <br /> FILTER BED ❑ Distance to noarsit, Wall Founearion, Property Line <br /> SEEPAGE PITS 11 Moth _ -Sire Numaer + <br /> SLIMPS 1.1 Distance to nearest; Wdi Foundation Property Lina <br /> DISPOSAL PONnS Q <br /> 1 hsraby certify that I have orsoarad this application and that the work will be done in accordanun with Son Joaquin coun(y oedwarcos,•staw Laws, arta <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licansed apem's siunature certifies the foflewina: "J certify that in the po-fannance of the work tot wt)ith tows 9wernt is;mead, I shall nat <br /> employ any person CIM as to become subject to workman's compensation lava of California"Contractor's hiring or suDtontracting signature <br /> certifies the logo n :"I Ice y it in torr Ace of the wrork far which this permit is iss.,ed,I shall employ parsons subiact t0 watkman'a coloIxi hse- <br /> tion iawa of C or <br /> T Mw apoicam can or plots drawing o n rsuerse side. <br /> Signed K_ Titre: Frr,jacr�f' �rt— t�T Data: 08 i'rlarrh,�fi,___ <br /> l FoR DEPARTMENT USS ONLY is (�� <br /> AppI+G��iGr+Accepted by Date / ,..— Arco�__------- ,-, <br /> Pit or Grout Inspection toy Data _ Final Inspection by Dom <br /> Additional Comments: w _ <br /> APPti.cont - Hetura all copies to: San Joti4ulu County Public Health Services <br /> Sovironnental health Pertilt/Services <br /> 445 to San Joa&—o� <br /> sox 2009, Stltnt CA 95261 <br /> IEEENFO AMOUNT DUE AhfOuhT REMITTED HEGEIYED BY �^PATE PEHµII N0. <br /> Hi v._y <br />