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APPLICATION _ <br /> SAN .JOAQUIN COUNTY PUBLIC HEA TIlFcCAVI6F9L--�` <br /> ENVIRONKENTAAL HELLTH DI <br /> 445 N SAN JOAQUIN, PHONE (2 =34`14----1.-t 1.+=-------- <br /> P 0 BOR 2009; STOCKTON, <br /> PERMIT EXPIRESYE R FROM A r d$UED (�s <br /> (Complete in Triplic' i. <br /> Applicstion Is hereby made to San ;oaquin County for a permit to construct and/or install the work herein described. This <br /> application is aide in compliance vith San Joaquit. County Ordinance No. 54 and 1862 and the Rules and R:qul.etione of San <br /> Joaquin County Public Nealt9)ServI es <br /> ��� <br /> Job Address ` � LI�Y <br /> Owner's Name o "—" 7 f C Address n__a.�?�`` ?f t C P,,one _�C 705 <br /> ConlraclR_L 1 �!�-Address L.cense No_3_%$2"7(e. Pnane <br /> TYPE OF WELL/PU .P r.EW WELL u "LLL REPLACEMENT 11 DESTRU(�PION Ll Out of Sarvfce well O <br /> PUMP INSTALLATION C SYSTEM REPAIR OTHER C Monitoring Well El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO, PROP.LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WILL U P <br /> INTENDED USE TYPE OF WELL PROBLEM ARcA CONSTRUCTION SPECIFICATIONS <br /> P. n <br /> -Industrial <br /> CTO Bottom LlManteca Dia of Well Excavation r'1�f►rof Well Casing <br /> (I Domestic/Private 0 Gravel Pack Cl Tracy Type of Casing_.___.— �t bfEatMh�rr <br /> I'I Public fl U-er Il Delta Depth of Grout Sea. ��ax4'�f,�iftwli <br /> , <br /> 11 ltrigatgn __Approx. Depth I I Eastern Surface Seal Installed by br <br /> ___ U11 11 <br /> t Repair Work Done L' Type of State Wo o}Pump - E'fJ�b!�+ <br /> Well Destruction O Well 0.^.refer Sealing Material i Depth <br /> Depth Filler Material <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR ADOITION� OESTRUCTIO lic INo septic system permitted if pubsewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Z Commercial_ Other J <br /> Number of living units:—L Number of b s <br /> " Character of soN to a depth of 3 fest: -�sf Water table depth <br /> r <br /> SEPTIC TANK � Type/Migz.!!1�• �S Capacity- No.Com)0490a-'�;J? <br /> PKG.TREATMENT PL1 j r /y,tt Mothod of Oisgosal <br /> Distance Ito rearest: Well_„2 7 Foundation Property Line 1 <br /> LEACHING INE _ �No.6 Length of lines _(1 _,r_.. _ Tavel length/sire <br /> FILTER BE f [7 Distance to nrtarest: Well.�f Founcist,on—�� Property Line—S <br /> i <br /> SEEPAGE PITS Depth •Size M - ��Ny�mber <br /> SUMPS LI Distance to nesrosc Wall�� foundenon Property fine <br /> DISPOSAL PONDS Cl ` <br /> j )hereby certify that I have prepsrod this appl,cation and that the work will be dont in accordance w,th San Joaquin county ordinances,state laws,an <br /> rules and regulations of the San Joaquin Countv <br /> ►lomis owner or ficensod agent's signature carru�os the following:"I certify that to the performance of the work for which this permit K issued,I NtaN not <br /> employ any person in such manner as to beer,:w subject to workmen's compensation laws of California."Contradlor's hiring or sob-contracting signature <br /> y cerlifi"L':.0"ov.9ni:"1 cerilty that in ins psrtvmonce of the-work for which this permit Is issued,I shall employ persons subject to workma:'s compenSa- <br /> i tion Iowa of Cadfornia." <br /> s TM applicant m Jt`cfor NI u sr�orons. Complete drawing on roverss I'de,/ <br /> ,x x _ Tnle: <br /> - X t Date: <br /> 4 <br /> Signed - <br /> r FOR DEPARTMENT USE ONLY rf� <br /> YY Application AeesperJ by r int Date �1 Ana <br /> 9 <br /> �or Grout Inspection by tDateu F nal inspection by <br /> Addnional Canmerts: �- <br /> Applicant - Return all enpfee to: San Joaquin County Public Ifealth Services <br /> Cervices al lfealth Perm l <br /> nay 4 SanJoaquln209. <br /> Stkn, CA 957.01 <br /> FEE AMOu T CUE T A.MOu f REMITTED agow RECEIVED BY D TE PERMiT N0. <br /> INFO / <br /> [N IY74 III CJ.�/n!I /% { <br /> 1H lr 70 -- <br /> r <br /> i <br />