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m r <br /> .�.., PAI <br /> APPLICATION FOR PEPUIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br /> FNVIROMMENTALT HSAI.TU DIVISION iY J 'Tay <br /> P 0 BOX 2009, STOCKTON, CA 95201 �� ��� <br /> (209) 468-3447 +�r <br /> -PER1dIT EXPIRES 1--UAEt FROM DACE ISSUED AP <br /> (Calnplet:e la Triplicate) � `4 l9gT <br /> Application is hereby mads td San Joaquio County for s perselt to construct and;or inat'ra'Rrr orc } Mdn■c 'bed. :::ia <br /> appyicatl0p is sxds In cotspliartce with Sap Joaquin County Ordinanceand No. 549 and 1862 tit y/ `urr'irypa or San <br /> Joaquin Coupty Public Heald.services. r r $ <br /> Job Address !SSS (.✓p�a.or /1,�1,tire City LYtL 4F 1.. Lyot sl:e/Acreage <br /> Ownef�a Name – l ruL � Andress "I�, 1 �'S cvl �'f l� i-�l.�r. Phone 61CO T11—ItS <br /> Conllaclpr i0.!' Address//fj Z � ��7 _ LiCens! No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service well LI <br /> PUMP INSTALLATION R SYSTEM REPAIR 0 OTHER F Nonitdrittff well <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP,LINE <br /> FOUNDATION ��� AGRICULTURE WELL _ OTHER WELL _ PITSISUMPS <br /> INTENDED USE TYaE OF WELL PROBLEM ARE CONSTRUCTICN SPECIFICATIONS <br /> Ll Industrial ❑Open Bartom t7 Manteca Dia.of Weil Excavation Oil.of Weil Casing .- to.- <br /> CJ <br /> rU Dornastrc/Prlvate SI Gravel Pack 0 Tracy Type of Casing SL 40 PJC. Spscllicatwns . t <br /> M Public 11 Olhar 0 Delta Depth of Grout Semi 18 4- Type of Grout <br /> ri Lllgstion Q "—4--�,_.—AOptoa.Depth F Esslsen Surface Seet Installed by <br /> Raper Work Dona ❑ Type of Pump H.P. State Work Dora, <br /> Wen Destruction 0 W14 Diameter Sealing Nateri&I i Depth <br /> Depth Filler Notarial It Depth <br /> TYPE OF SEPTIC WO—RA: NEW INSTALLATION 0 REPAIRIAODITION C1 DESTRUCTION CJ fNo septic syslem perrrwtted It pubflc Nwer/s <br /> wallabls within 100 feet.l <br /> Initaaation will Be", Residence_. Commercial— Other {� <br /> Nurnbaf 01 4virfg units:_ Number of bedrooms <br /> Charactw of god to a depth of 7 Ieet: Water lebte 600th <br /> — <br /> SEPTIC TANK ❑ Type/Mfg CapacrtY No.Compartment <br /> I PKG.TREATMENT PLT_L1 Method o1 Disposal <br /> Distance to nearest: Wen Foundation _. Property Lina C <br /> LEACHING LINE Ll No.S Length of fines Total lengtrt/sena <br /> FILTER BED CI Distance to nearest: Wed Foundation Property Line <br /> SEEPAGE PITS i 1 Depth _Sire Number <br /> SUMPS L1 Diatoms to nearest: Well Foundation Property Line <br /> DISPOSAL PONOS Q <br /> t horsey ClInIfY that J have prepared this application and that the wart will be done in accartlance with San Joaquin county oralnancss,state laws,and <br /> rules and regulations of the San JOaouln County <br /> Horn owner or 11CanNd agon1'1 signature candies the lonowingl"I certify that In Ina ParfoMitnel of the work for which this permit is iSf Ued,t shalt nor <br /> employ any parson in such manner It to become wblact to workmen's comeansahon awn of California."Contractor's hiring or sub•eonuacting signature <br /> comfias the following:"I ceruty that In the performance of the work for wfirCri this permit it issued,I shalt Imploy person$Subject to workman's Compansa• <br /> tion laws of Califdrnla." <br /> The apWiu ust 34 for ek required ins c I Complete drawing on reverse side. [� 6 <br /> Si90@d 7tb: Dale: <br /> FOR DEPARTMENT USE ONLY <br /> Appl'aon Accepted by ✓L Dat Area <br /> Pit at Grout Inspection by Data Final tnspscucn by pat! _ <br /> Additional Commentat <br /> Applicant – Return Itll triples tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICE3 <br /> 145 H SAN JOAQUIN. P 0 Sol 2009, STUCXTON, CA 941701 <br /> FEE INFO <br /> AJrT Out I AMOUNT REmirrfO a EIVEO BY OAT( PERMIT N0. <br /> Irl mos jaav 11411 iiA <br /> {,�..j�'�J <br /> .. IM:a.� r� "OILr <br /> 1J <br /> e��7rit11Y <br />