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APPLICATION `
<br />�o-
<br />. �I SAN JOAQUIN COUNTY,PUBLIC HEALTH,
<br />ENVIRONMENTAL HEALTH , D I V I S I
<br />> 445-N SAN JOAQUIN, PHONE (209)46 i
<br />P 0 BOX 20090STOCKTONf,''CAa95
<br />TAC
<br />1994
<br />FJW IRES IYM FR '` D TF
<br />(Complete. in Triplicate),' KIT, E
<br />Application -is hereby made to San Joaquin County for a permit to`construe-t and/6r iribtali the, ren asci e . s
<br />application is made in compliance i.ith San Joaquin County Ordinance N$. 549 and l 6 Acid f:he Rules and Regulations of San'
<br />Joaquin County Public Health Sery ®g y Aas17� p i!„r p •.� ; -
<br />/7" %✓ t t�'� r
<br />at
<br />BetWee21 AL1StjT1 Rti NeVJ CaSti@ 12�_ Cit Pk&k � Lot Sloe/AcreaReApp�'os,
<br />Job Address
<br />140 A CS
<br />Cit of Stockton 425 E1 Dorado
<br />Owners Name Y I Address Phone 209 949-$341
<br />` 4230 .Kie,rnan 'Avor to x105
<br />The wining Laboratori eNr7506159
<br />209 545"10 0contractor ,ass 535cs.o
<br />Phone
<br />TYPE OF WELL/PUMP: NEW WELL (R WELL REPLACEMENT n ,o-O,J` ,DESTA CTION Cl Out of Service Well_�0_ ,�?
<br />PUMP INSTALLATION O SYSTEM REPAIR ❑ `. 'i OTHER ❑ Monitoring I1e11 Lj
<br />DISTANCE TON REST: SEPTIC TANK '-"� SEWER LINES?Q© "�'�DISftOSALrj f�Q PROP. LITS 5Q 1 OO
<br />FOUNDATION12-0-0-1-L,
<br />AGRICULTURE WELL200 bTliEil;lAl'L`E' 200, FITS/SUMPSt
<br />�Site
<br />INTENDED E a . ' `T`Vk OF'WELL PROBLEM AREA £t CONPE
<br />STRUCTION
<br />Wen TION Stion f C, TItiN � r Dia. of Wap Casing j §
<br />n Industrial ' ❑ O n Bot m ❑ Manteca rir+i7 x` s
<br />C.l Domestic/Ovate 00 Gravel Psck ❑ Tracy z
<br />i Type ofCasing.SCW „ Wria�JC�pecifca.
<br />j�Z1w.
<br />a I'1 Public fa Other \1 Delta Depth of Gout Seal. Q t t `• j £ type o SctYiCZ-CQRent
<br />f Grout
<br />M I f irrigation/Done
<br />_ Approx. Depth ` I I Eastern Surface Seal installed by .�
<br />Repair WO, U •Type of Pumpp � @ H.P. _ n/a __ state WorkYDon6 S probe installatiana
<br />1 We11 Dest tion O Well Diamet r -i Ch Sealing Material Z Depth than .Ct±�i+ lw is '
<br />I ,., aa, y
<br />o Depth . 1$'killer Naterial b Depth S613d °al lirrv, '
<br />TYPE O SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION 1 1 DESTRUCTION 11 INo'teptle,system permitted it public fewer is { z !
<br />1 available within 200 feet,I °0'
<br />Insts ion will serve = Residence ____ Commercial ' Other
<br />, § a
<br />NU f Of living Units: �< Number of bedrooms a4 •�: i .. ,:, .. ,fie a r�'a �«wr aww,N;gy,�+� x �: r,..•� - �
<br />3 Cha ter of soil to a depth of 9 feet: I Water table depth,-
<br />to
<br />epth" t
<br />SEPT TANK O Type/Mfg Capacity a f+lo compbrtmentti'
<br />A.
<br />. •'� PKG REATMENT PLT. O x
<br />� , r Method of . Dispoutl., '
<br />Distance to nearest: Weil Foundation i?tbpbtty Line &&#
<br />.++..w�..�
<br />t,. �„ d', ax k+•nxa. .gy. tF. .,q-: �9..,o g ;..
<br />t i
<br />LE ING LINE 0 No. d Length of lines. Total lengthisize' 1
<br />FI R BED ❑ Distance to nearest: Well Foundation Property Line ° 4�4
<br />` , Y , . , t, J �s . 0o- a t '�. � u* A • �, z w � u .,,+ .;t ;�x$aa ,.�£..
<br />r AGE PITS I I Depth Size
<br />PS Lf "Distance to nearest: Well Foundation "Property Line I I
<br />-
<br />POSAL PONDS
<br />f reby certify that 1 have prepared that application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and °
<br />s and regulations of the San Joaquin County o
<br />i me owner or licensed agent's signature certifies the following: "I certify that in the performance of the It for which thWpermit is'issued, I shell not
<br />ploy any person in such manner as to become subject to workman's compensation laws of Catrtomis " Contractor s htrinp of sub contracting signature '
<br />lfie$ the following: "I certify that in the performance of the work for which this permit is issued, I $hill ernpldy persons subject to workman's compensb
<br />n laws of California." t
<br />I
<br />e applicant trust call fo ,l required inns/p*t-ions: Complete drawing on to rse tide.
<br />g gn" X' rg L��r Title:
<br />f Date.,S7` i
<br />=FOR DEPARTMENT USE ONLY ri 3 o
<br />ppiication Accepted by ii.�Y- S t % .Q i a
<br />Date Area
<br />bate
<br />or Grout Inspection by r
<br />Final inspection by Date,
<br />// 4
<br />dditionai Comments:
<br />A 7r,
<br />a i + Ilj
<br />pplicant -Return all copies to: San Joaquin County Public Health §erviee *`}
<br />Environmental' Health Periait/Service$ ,�� • �'�-'..
<br />445 N Ban Joaquin, P O Box 2009I Sikh, j, 626 t i
<br />Y
<br />ii 4 IREV. 1/" 51
<br />INFFEE
<br />AMOUNT DUE
<br />AMOUNT REMITTED
<br />K
<br />RECEIVt2d by
<br />b TE PERMIT' NO
<br />
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