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„it,ATION
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<br /> aN .tr�r r�lisi fC f3�iAi."if
<br /> 5;.•�',v
<br /> ` �1 T CES
<br /> HEALTH
<br /> •145 N L r PifON� < r.r
<br /> P 0 far. (2U.ji ,a8-342U
<br /> •�'KTON, CA 95201
<br /> 1 r;
<br /> ._.�.L� L//r''`3. :L._:� lil
<br /> 01_
<br /> Application
<br /> rip
<br /> :Pp-lcetlon t” r.ry ro q�n Qu1n —'arty for e p =,,;t t,, cowitruct er,;i/a :ns all the work htrrin described. This
<br /> JpDlaetico Ss r,"*. to c""I`:isno•+ with San Joaquin Cot,nt;' 6:dl fence No. L and `tl
<br /> oLquln County F`.i.,i7 F'.alth r•ry;c,.e, 5 9 , ko? and the Rules and Regulations of San
<br /> Job Address Y c. _
<br /> _ ' �!_�-?'4'/ Coy+��� Lot Sisr/Acreage
<br /> pAddress
<br /> V�Contractor / /��,�_ A L�
<br /> tltlress
<br /> TYPE OF WELLIPU!Ja -- — - - L,cesse No.-_ Phone
<br /> NEW WELL 7 WELL REPLACEMENT , OESTRUCTIpN Ll Out of Service Hell [}
<br /> PUMP INSTALLATION " SYSTEM REPAIR
<br /> DISTANCE. TO NEAREST. SEPTIC TANKOTHER 0 wotiitoring Hall �
<br /> $EWER LINES _ DISPOSAL FLO. PROP. LINE
<br /> FOUNDATION _ AGRICULTURE WELL __ OTHER
<br /> INTENDED USE TYPE OF WELL PROE'LE.t AREA OTHER WELL PITS/S—u)mp$ _
<br /> .l Indusinaf C Open{9orom - CONSTRUCTION SPECIFICATIONS
<br /> Manteca Dia of Wall Eacevation
<br /> i Domestic/Private Cl Gravel Pack Dia•of Won
<br /> ons
<br /> Casing
<br /> Tr
<br /> Public Li acy Type of Casmg- $pee,f,caa1
<br /> i1 Other !1 Delia Depth of Grout Seal '�—
<br /> !Irr,pntro^ __ ApproR Depth ! I Eastern - Type of Grout
<br /> Raper Work Done L' T Surface Saul Installed by,_
<br /> Type of Pump H p
<br /> Well Oostrucnon a Well D ameter Sealing jfatrrial Z Dryth State Work pone_
<br /> Depth Fillrr Material b Depth^�
<br /> TYPE Of SEPTIC WORK. NEW!NSTAt.LATION I I REPA•R rA001TtON i pt$TgUCTIOjY jR INo straw` r
<br /> awaabla w,thme2G0 feet t,ad i!Public wvrat u v
<br /> Number of liil serve: As Commercrsi�
<br /> / Otnyr
<br /> Number of living units: Number of bedrooms
<br /> Character cf soil to a dspth of 3 feet: �-
<br /> SEPTIC TANKO Type/M} —�—` —- _.Water table depth /
<br /> g .y ,..� ✓
<br /> PKG. TREATMENT PLT.[DCapsuty _ No.Compartments /
<br /> Distance to nearest: WellMethod of Disposal
<br /> Founder on Property Line
<br /> LF4CHING LINE 0 Nr 6 Length of lines
<br /> F,LTER SED .-_._ Total length/sl:o
<br /> CI D stance to nearest: Well Foundation
<br /> Property Line
<br /> SEEP. :c PITS Det rh
<br /> Site _ Number
<br /> SUMPS L Distance to nearest: Wall
<br /> DISPOSAL P OS Foundation C7 Property Line
<br /> I hereby ce ,fy,that I have P Dared th!s appl,ca an end that the work will be done,n accordance with San Joaquin �+^
<br /> ruler and ulatrons of the an Joaquin Count; eQ County Ordinances,State Iiws,0r5"d
<br /> Home o r or licensed ag is signature csrtrffes the following: "I tort ty that in the performance of the work for which this perrrut is issued,1$halt not
<br /> or'�oY ny person in such ^net
<br /> eertdgr iho foltpwm+y tMt"a to become sublect to workg sr
<br /> man's compensation laws of California."Contractor's hiring or sub-contracting rng:"1 ,. Lie rt
<br /> tan lormeneo Of the work this work for whav�ts.of California, permit n issued.I$hall employ persons subject to worknssn'a compansa-
<br /> The al:k;t,ptt must fob v inspections. Complete drawing on reverse%,do.
<br /> K 19 Title: , r"Iy.L, _/rT Q l9
<br /> Date:
<br /> R DEPARTMENT t1Se ONLY
<br /> Application Accepted by 1!�
<br /> Date.� - � .Ata
<br /> Pit or Grout Inspection by 1
<br /> Oae am$I Inspection by '4Z
<br /> t/�.! Dae
<br /> Additional Comments:
<br /> Applicant - Return All oo;'fnq to: San Joaquin County Puylic llnnith Servlcea
<br /> Environmental tlealth.Permlt/Scrvicoe
<br /> �-� 445 N San Joaquin, P. O Dox 2009, Stkn, CA 95201 qQ�r-
<br /> tNfO
<br /> AMOUNT Due f AMOUNT gEM!TTED It
<br /> CASH AEC:IVED BY DATE PEAMi7 N0.
<br /> C.13 24 14X111 N.era it y1 '7 •�.' f�� 1
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