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I <br /> . j • <br /> APPLICATION FOR PERMIT <br /> i= SAN' JOAQUIN COUNTY PUBLIC HEALTH .� <br /> ENV I RONYESNTAL IiEALTH I I V I S I <br /> 445 N SAN JOAQUIN, PHONES (209)4 ��� <br /> P O 807[ 2009, STOCKTON, C 99 Moo <br /> .R <br /> PERMIT EXPIRES �a L R� <br /> (Complete in Triplicate) --I <br /> Applicatl o is herstedebn�e�toBanliLrice vlthuilL County <br /> Joaquo r a Py Drdtnancto a Nrmit o. 5L4struct aand o18W and tw Rules am I'leaulatlonsof San <br /> r III-at—ALL, a <br /> Joaquin County Public Health Services. <br /> ,s ccrc <br /> r � t/A' City�(,PC eh Lot Sise/Acre�e <br /> Job Addr*u I <br /> Address r-O "0 x— -� w Phone <br /> Owner's Namedafc..G+(,Q,1. <br /> a" 94SL4-1 01z / <br /> 3x9f Ffrk2 oz zo Phon44A' SfiSl <br /> �K ,,, fnC.Address,_QE"x�1e--���-� —License No,_ <br /> Contiacta vrr4c/ eWell 0 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT fl DESTRUCTION ❑put �Lto'sna Yell j <br /> SYSTEM REPAIR ❑ OTHER 13S <br /> PUMP INSTALLATION ❑ 7K6' PROP.LINE <br /> >�r SEWER LINES >� DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK 7�, AGRICULTURE WELL OTHER WELL ala SlSUMPS <br /> FOUNDATION <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS kr`�' a <br /> INTENDED USE — .of Wan[s ' 2 <br /> Cl Industria— ❑Open Bottom O Manteca Die.of Well Excavation C <br /> Type of Casing_p� Specifications �� 4 <br /> 1-1 Domenic!Privets ❑Gravel Peck ❑ Tracy Type or Grout O. eaA.erf n <br /> PuNk h3011+ar <br /> fl Delta Depth of GroInstalled <br /> tale �� r \1N1 <br /> 's5 Z.f�.Approa.Depth I I Eastern Surface Gaul Insu1{rd by <br /> Repair Work <br /> �1 <br /> Pump H.P. _ Sure Work Dona <br /> Repair Work Done C7 Type o � eselins laateritl i Depth <br /> F Welf Cleelructlon ❑ Wag Dimu <br /> aar <br /> - Depth� >r111er Itatarial F Depth 1 <br /> fj TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRlADDITlON i I DESTRUCT:ON I t aNadlbb'within 200 test.) <br /> it prrWx MMW n <br /> q; <br /> x eta gition vA serve: Resrderta <br /> m « Commercial^ Other <br /> 'e Number of bedrooms_ a <br /> Number o}yvl�y urlts:�_ —Water table depth <br /> Character of coal Is a depth of 3 feat: Capacity No.Compartmantl <br /> SEPTIC TANK. ❑ Type/Mfg Method o <br /> PKG.TREATMENT PLT.❑ <br /> r. Distance to Merest; Wen Foundation Pfope:V Line <br /> 5. Total leng,hfeixs <br /> a —ft Ali 0- <br /> LEACHING LINE ❑ No,•Length of Sn*s . <br /> ClOlatenee to nearest: <br /> Well foundation Prol„ny Llfw <br /> . <br /> FILTER BED <br /> $iia Humber------- @ - <br /> SEEPAGE PITS I I Depth T Props”Line <br /> 1 <br /> SUMPS LI Distance to ner <br /> eeat: Well_ Foundation <br /> r <br /> o DISPOSAL PONDS ❑ <br /> I hereby certify that I hrw prepared this application and that the work will be done In accordance with San Joaquin county o'diruncee,state latus,and tf _ <br /> ruNa and reptrlstlofts of the San Joaquin county <br /> Norms W(I r or Licensed agents elgnaturs csrtilise the following:-I certify that In the performance of the work fa which this eermt h:.awd.I rlluIt no <br /> en+PIW any person in such"And!as to batorne subject m workman's compensation laws of California."Contractoion�;b�ct o r YI18cling signature <br /> mN i cattpenaa-. <br /> cendiea the following:"I certify that in the parlormance of the work for which this permlL is issued,i shall*mploY Pe <br /> r tion Taws of California.' <br /> iThe applicant el ease[or eN nqu edJ3n/sem'tions,Complels drawing on rwuw aide. <br /> - `;(- <br /> 0 <br /> Dsu: /tP ¢ - <br /> Signed f <br /> FOR DEPARTMENT USE ONLY <br /> Dns ` Arte ! . <br /> Applkallon Accepted by Z QY <br /> i Find In by <br /> PM or Grout Inspection by <br /> Dot. <br /> AdditionsCortv►+nn: <br /> l Applicant - Return all copies to: Ban Jnaqutn County Public Health cervices <br /> t \ - 'oviraanentll Health Permit2009, cea <br /> It1,,/' 415 N •9an Joaquin, P 0 Box 9000, 6tke, CA 96701 <br /> _ 351 <br /> AM*UNT REMITTED RECEIVlD aY DAT[ fERM1T'NO. i <br /> f91 AMOUNT DUE <br /> ddd Fa <br /> } V <br /> .t6113-2s,ad. ae <br /> ter W46 <br />