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s .. . . <br /> APPLICATION <br /> a <br /> SAN JOAQU I N COUNTY PURL I C HHALTB SERVICES <br /> ENV I RONW(TAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOE 2009, STOCKTON, CA 95201 <br /> PLUIT R"IR&O 1 X R FAOH DAIE ISSUED <br /> (Ccoplete in Triplicate) <br /> I.� <br /> AMuctuas to heretry sade,to ban Joaquin County tot a p,roit to construct wWor Install the vort herein described. This t` <br /> soltCounIs loado Is e2*1110ce with <br /> fro Joaquin County Ordinance No. 549 am 1W aid Us mules am Rqulattate of Sen <br /> olta <br /> JobAddrase 4,02-j N. -99 FRONTAGE_ --- c,tv SIQCKTO I Lot ltsu/Aereeae <br /> { Owrw'sgame SHARON SCUSER Address 6333 PACIFIC AVE. SUITE 281hone 931-905 <br /> + <br /> Contucta I'FJNINGS W. DRRIM COAadre[t 3525 PELANDALE AVc.LK.n,e Ho. 290813 Phone 545-1185 <br /> t <br /> TYR 60 WELL/ V : KLW WELL 0 WELL REPLACEMFNT n DESTRUCTION W Out -01 Servite Val1 <br /> PUMP INSTALLATION U SYSTEM REPAIR 0 OTHER O (dattortltE Wil O til <br /> OISTANCE TO NEAREST: SEPTIC TANK __ SEWER LINER DISPOSAL FLD. PROP.LINE <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL—2.01— PITS/SUMP! '} <br /> N � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> n tndut"wo O Open Bottom 0 Menlo" DA.of Wes Eaeavation Dia.of Was Coskv }t ' <br /> Cl Domtab/Prlvete 0 Gravel Pack O Tracy Type of Cafnp_ SpeelRcottone <br /> VI Pubne t.I Other n Dehs Depth of Gr" Seal Type of Orout 6 ;y <br /> I 1 Inpnbn Appma.Depth I I Eastern Surface Seal Incased by <br /> Repair Wan Dons U Type of Puny c H.P. _ 3 �RI <br /> 97 -09eymil— <br /> Woo Destruction III WN Diameter r_y' Balla{Material A Depth <br /> ,R <br /> Death <br /> t tiller llsterW 11 Depth <br /> Yf Q SEPTIC WORK; NEW INSTALLATION I 1 REPAID/ADDITION I I DESTRUCTION 1 I INo upne[%atom permnud H pubk seow Is <br /> evadable vothin 200 foe.) <br /> Inotosatbn err sans: peoldence_ Commetcisl_ Other YF <br /> MNttber of h+M+O u+ke Number of bedrooms k <br /> i Chafactor of soil to a d@VM of S feel: Wstor table depth <br /> SEPTIC TANK O Type/wp Capacity No.Cofnponments <br /> i PKO.TREATMENT PLT.0 Method of Disposal rj <br /> Diatoms to noww: Wee Fourdatbn _ Pfopsrty Lha <br /> LEACHENa UNE C1 No.&Length of tines Total bngoiysire_ y , <br /> Ip; FILTER SED 0 Distance to%cornet: Woo Foundation rrOMW Lk% <br /> SEEPAGE MTS 1 I Depth Size _ Nur-Al' . r <br /> SUMPS LI Distance to nearest: Woo Foundation i'Nperty Line f <br /> DISPOSAL PONOS O <br /> 1f 1 hereby Sanity that 1 have prepared this application and Chet the work will be dorm h accordance with San Joaquin county ordiia1.c9 state laws,and <br /> mise and repndstiona of the San Joaquin County <br /> Homo owrw at lkensed agsnt'o gpnaturs canifes the Yellowing:"I ea.'fty that I-the p—fotmance of the wort for which thio pend% + +an i,!Ohio not <br /> enplby env perawin such mennsr as to Cocorne U-ti et to workmen's compso" on Ift"of C"'omia"Contractors hiring Of sub-cot trectkv signstute <br /> amtlflee tM hisotAdng:1 certify that in the performance of tht work lot which this pern-A is imuod,I Shap employ persons sublect to wotkmsn's carnpenae• <br /> 9• tion taws of cowornis." <br /> The OpplkeM must t:ao fa ee hapset .Complete rewraver++ be. <br /> &� signed Title-: ` �-- ate: 9-25-91 <br /> + ' FO DEPARTL4ENT USE ONLY F <br /> i Apr,%Otion Atcertad by �Y�• — t`' Dale , At.. <br /> C <br /> Pit or Grout Inswtion by Dais Final Impaction by sato 2 <br /> e � C <br /> Addkloral Comments: <br /> t ApP1lcAnt - Return s11 copies to: San Joaquin County Public Health Servlcee <br /> Bnelrooaront% Health Peralt/Services ,(��►A <br /> 445 N San Joapuin, P O Boa 2009, Stkn, CA 95201 Jw� <br /> r[[ AMOUNT Dui AMOUNT REMITTED <br /> INFO CASM REC[IVED ay DATE PERMIT'NO. <br /> __ <br />