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<br /> APPLICATION
<br /> SAN JOAQUIN COUNTY PUBLIC HFAITH SERVLCES
<br /> ENVIRUN1 EN—rAL dEALTH DIVISION i
<br /> 445 N SAN JOAQUIN, PHONE (209)168-344
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<br /> P 0' BOX 2009, STMKTON, CA 95201 1
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<br /> RIMMIT ESPIRES 1 YEAR FRG,M DATE ISSUED I
<br /> (Complete in Triplicate)
<br /> Applic+tioo is hereby ,Wade tc 34h Joequl.n County for a permit to ecnstruot. and/or :.rstBl+ the vorkiherein dTec-abed. This;
<br /> sppllc4tion it tasde in complia.,-tce with San Jongsin County ord:narze No. 51+1v and 1.862 mix.' :the Rulesiamd Reguldtioaa of San
<br /> Joaquin County PubJ1e Health Sarvicea. i
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<br /> Job Address _ :`�oxU4�f�A�r.:..:.ri lro � ��{„ --- C''v��Si�, r.�`c_ `F Lot Size/Ac+Me
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<br /> Owner's Name ,W11 rrn _ ,,.1is»IC--- _ Adores, 35215 Ai5�wc,,A33) Ve"(,C&.53 �,�t PlAnna
<br /> �1QM-�i�S�, I��-c,kCk
<br /> Cor.hactor_},a�Y.�c ,Eluda'b?Ls.t tlsrL•_ Address .171. 4gL�p DL���11a+LMf �a�+en Nn Phone -v
<br /> TYPe OF WELL:PUMP MON WELL G WELL REPLACEMENT OESTAUCTIOtl 5&1 Out o. Service WelL.
<br /> PUMP WSTALLAT10N 0 S`/STEM REP,'-;R lttaw�by r',,y OTHER 0 Monitoring Well 43 .
<br /> O:STAKCE TO NEAREST: SEPTIC TANK _ SEWER LINcS —. DISPGSAL FLO._ PROP. LINE � !
<br /> `^ FOONCATION _J ACRICULTLRE WELL OTIIER WELL PI $/BUMP$
<br /> Ir4TENDEJ USE TYFE OF WELL PROBLEM ARFA CONSTRUCTION SPECfFICAT;UNS i
<br /> Industrial U Open Bottom: ;J Manteca -� 04. of wail Excavation i ,�t� �.. Dia. if Well Casing ki i Ni
<br /> F* Domestic/Private 0 Grrovii Pack 5d T.,aclkd Irnc�\. Hype of Cann Spec ficatron,
<br /> i'! Public C)?I Other Cl Del'a Depth of Grout Seat 11001Type of Grout YL&
<br /> + IrngattOn 4 Approx.Ongth • ! Eastern Swlace Seal Installed:+y
<br /> Repa•r Work Dane U0 ►T�y�p�ee of Pump H,P, _ State Wbrk Donn r li
<br /> Well Destruction 13 44a1i"Diameter T2s tom_ Sealing Material it Depth
<br /> (depth �' IQ �� Piller Nnterial L Depth
<br /> TYPE OF SEPTIC'WORK. NEW It I >rn Oiltmitred if outlic sewer is
<br /> 2001 1.)
<br /> Inaraketira„will serve: PesiOencu post-it"Fax Note 7671 D ► f
<br /> Number or living units: r !tort Fro
<br /> Charactar of cod to a depth of 3 — pI4 ►la depth
<br /> SEPTIC TANK U TWs r'rt� oaK is
<br /> PKG•TREATMENT PLT-::1 P �o�Sid_c�� Phone q e--N L: f Diep sal
<br /> Distar ) ' !-r Fex , .2 o
<br /> LEACHING LINE Q No. & I.ertjtm of tines 7ats1 length/site
<br /> FILTER SED Distance :p nearest: Well Fovr,Cation Property Eine
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<br /> SEEPAGE PITS + , Depth Site _,.. Ntj:Ttber
<br /> SUMPS L' Distance t nearest: Weft Foundatioxt Property Eine
<br /> DISPOSAL PONDS _G 4
<br /> I hereby certify that t have prepared this;applicatiot+and that the work witi be acne in accargonce wrth San J6bovin coon,Y ordinances, stale laws, and
<br /> rubs and regulations of the San Joaquin County II
<br /> Ht)ei4 uwrrtr o-licensed agent's signature comfles fbo fohowing: i cerllty that is the performance of the work,for which t>♦Sis perrNt is issued. I shall not
<br /> emplCY any person in such manner as t4 become subject to workmar.'s compenswicn 4w-Gf California" ContKector'i miring or sijo-contracting signature.
<br /> Cartifiea the`o!>ownp: "I Comity that in thi pmlormanGN of the work for whieh Thia"ermit a•4suad; I shol,•r•GtoX parsons sv at to work rar•'a Gompense•I
<br /> tion lows of California ' I I
<br /> The applicant mus elf 1!sj gf Equi e<1 ir,6pections. Complete crawing 0 r rse side,
<br /> Signed X Title n Oat : L2-? / bJ
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<br /> FOR DEPARTMENT USE ONLY
<br /> AAPllretinn dresptsd by
<br /> Pit or Grout Inspection by , �� Date — Fine; Inspection Cv– — - _ Date
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<br /> Adoitional Coments. I
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<br /> A},Nt.ic:nnr - Returr, :tit copies to: a Joaquin County P: lic Health Servloes
<br /> owi:'onmental Health Permit/Services I � �d
<br /> 445 N San Joaquin, P ,? BOA 2009, Stitn, CA <15204
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<br /> Ic AMOUNT 0►J`^EAMOUNT REWTTED l CK H RECEIVED SY DATE PERMIT,NO.
<br /> Page il3A
<br /> • WM 13• (AE's.+ .��I F I.
<br /> $4 1{- r,
<br /> Nrbu
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