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SAN )%dQUIN COUNTY PUBLIC HEALTH &AVICSS ,'•rs ,. r. <br /> ENVIRONYSNTAL HEALTH DIVISION ­ <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 - ! <br /> P 0 HOZ 2009, ETON, CA 95201 19592 <br /> 2ZAKIT-MIRES -1 YEAR EM 12ATE Law= <br /> (Complete in Triplicate) <br /> Appliestioa is hereby msde,t:o San Joaquin County for a peralt to construct and/or install the work herein described. This <br /> sppliest;ion is made in carplience with San Joaquin County Ordinance Ito. 549 and 1562 and the Rules and Ilegu Ban <br /> Joaquin County Public He/�altth Seryices.c <br /> Job Address <br /> /3.-00k(Id loo /� City C Lot B i se/Acreage o 13 ALS <br /> S r Address 0 Yf/�/00 Cww 2Qrr/ p-9 <br /> Owner's Nuns � L..v'! <br /> Qlrs LiK /lv A;Wa <br /> N .CpntrattoB� - ddess ' 0 <br /> TYPE OF WELL/PUMP: NEIN WELL M MAI-* WELL REPLACEMENT n DESTRUCTION ❑ Out of service 971=1 <br /> PUMP INSTALLATION O y�1 SYST M REPAIR ❑ sty' OTHER o,,-f��49-/wen <br /> ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK UA SEWf:{LINES Ot J5'N'1&SPOSAL FLO. PRO�rP NE <br /> FOUNDATION AGRICULTURE WELL . C= OTHER WELL�TS/SU PS ..— <br /> INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> •,� <br /> indust"' A1asr; -41)0 Open Bottom (3Manteca Dim. of Well Excavation h Dia, of Wen Casing 7 �'T' <br /> Cl Domestic/Private RcGravel Pae; ❑Tracy Type of Casing_ V✓G SDeCifiCations rem � � <br /> f'1 Public n Other n Delta Depth of Grout Seal 40-47 1r Type of Grow <br /> I keipnfon 4f Approx. Deptth''``I I Eastern Surf Seal Installed i1y <br /> Rspw Work Done (] Type of Pump � H.P. A, a State Worts Oona <br /> Well Desu"Cdon ❑ Was Diarneter Sealiteg flaterial. E Depth <br /> Depth FUJAW material r Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo septic system permitted if public sewer is <br /> available witNn 200 fest.) <br /> lrt mbdort twill sows: Residence_ Canwneteial— Other <br /> Number of Wing wails: Number of bedrooms <br /> Character,of Boll to a depth of 3 fest: Water table depth <br /> SEPTIC TANK o Type/Mfg Caps. NO. <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Wel! Foundation Property line <br /> LEACHING LINE ❑ No.A Length of linea Total length/site <br /> FILTER BED ❑ Distsnee to nearest: Wen Foundation Props"Y Line <br /> SEEPAGE PITS I I Depth Sise Number _ <br /> SUMPS LI Distance to nearest: Wan FowW*tbn Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby euWy that I haw prepared this application and that the work will be done in accordance with San Joaquin county ordinances. stats Iwws• and <br /> nAw and regulations of the San.Joaquin County <br /> Home ammo er licensed agent's sone"cw0fies the following: "I t:srtify that in the performance of the work lot which this pwuk is issued.I shah not <br /> employ any pow P in such rano as to become VA4W to wWkrrtsn's compensation lows of California."ContrecWS hklh0 of wb•00nt8etin0 signaettre <br /> cwofts the fallowing:"1 earthy that in the perfor vance of the work for which"pemtit Is isetm I chalk empty owoa ri subject to wwknwea eonV wm- <br /> tion Iowa of CsNomb." <br /> The applicamust ell for all required i nspeetions. Compute drew v on rev,.side.LSe_ Woo- <br /> nt ? <br /> S�r� t Title: �e"�lG ! •S/�' Dote• <br /> Mal- CJInG FOR DEPARTMENT USE ONLY Z •O� <br /> • �5 .9Z /Ll <br /> AppEt:stian Aegpted by Dan Ane <br /> Pit W ental 1 topeegon by ff ff Date �• Frn.1 trapeeMort by DNIa <br /> Additional Comment.: .,- B-I i o' i 3•q Mw Q ia•00.4 L -- -- --- <br /> Applicant - Return all copies to: San Joaquin County public Health Services <br /> ievirommental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stka, CA 95201 <br /> CIL a <br /> aQEEAMOUNT OtM AMOUNT REMITTED CASH REtI ww sY DATE PE mirloo. <br /> INFO <br /> j �' S2.3�- �'YIYN Y�v V-3ZI E d ' <br /> EN ib>♦ <br />