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r"i <br />APPLICATION FOR PEU <br />SAN JOAQUIN COUNTY PUBLIC REa <br />EN'V I EKMI(ENTAL HEALTH D <br />445 N SAN JOAQU I N , PHONE ( 2 <br />P O BOX 2009V STOCKTON , <br />H SERV I CES 6>Z9#1�.-r' <br />S Y ON1468-31120 ,0 <br />95200 <br />PF <br />AVIT F <br />(Complete in ' riplicat ��� _.. <br />Application it hereby :adt to San Joaquin County for a permit to construct vor)t bertic deacribed. This <br />s"llication in we" is compliance with Saar 3txagt:in Co=ty Ordinance No. 549 rind 1862 and the Aulta axtd Rtgalatiture Of Sun <br />joaruia Coiaoty colic Health ale r iCes. 'f .r <br />�� rti � � ! . �:, r . �,. � 71 ....• ��-d . x l'.l7 � z.nr. 9 t rrerlJtszlParaaae <br />Jo0 At &&= s <br />1 ✓ l <br />Address <br />en9raetttr.' /�te� r !> AddrtSs ,l"� , ' t it '� � Littnse No. ��' c 7 c* pyre �4- l am <br />TYPE Of WELL/PUMP- NEW WELL Z! WELL REPLACEMENT 13 DESTAUCTiON 0 out of Servlet W*12 <br />PUMP INSTALLATION u SYSTEM REPAIR 0 OTHER C; tdocitoring Well [] <br />DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL - --_ PITSlSUMPS <br />INTENOED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />C71 Industrial 0 Open 8oaorm C: Manteca Ole. of Well Excavation _..—___ Dia►. of Wou CA" <br />Ci Domesticiptivata CI Gravel Pack Ci T:acy Type of Casing__._ Speciticstiors <br />1'1 Ptabiic 1-I Other (-I Delia Depth of Grout Saat Tvpo of Grout <br />I I ItnuaWn — Approx, Depth I I Eastetr Surface Send Inatapaa4 by <br />Repair Wort Dare Li Type of Purnp _ _ N' P, - Stats Work Outs <br />Wall Oestiruction 0 Wall Diarristar So&liryl material i Depth <br />Depth Tiller Natarial i Dspth <br />TYPE Of SEPTIC WORK: NfW iNSTAiLATIt3N t i Al DDI TION DESTRUCTION t I INo septic syst*m pefattatd if public srwar it <br />r mavailable within 200 teet,f <br />InatasNation annul sawn, it nos � CO"Wristtiai Other <br />Nu"tber od tivinq units:Number of <br />Character of nob to a is epth of 3 feet: � / L ri i ` Wow tab o WWtth <br />SEPTIC TANK G Type/Mfg No. Comoartmwsts <br />PKG, TREATMENT PLT'. CJ T Method of Disposal <br />distance to reerast: Watt _, foundation ,_._. Property Lire <br />LEACHING LINE No. 6 Ltrigth of liner Talrt iangthlsize r <br />FILTER BED Cl Distance to nearest: Wail S7' J Ftwnaatwn � Pr,;"v Linc < <br />P <br />SEEPAGE PITS I I Depth � Sire.Xit"", Numtw <br />SUMPS Disuri A to twrrm: Well �. i t°` ` Foundation � PiroC40V Lire - <br />DISPOSAL PONDS Cl <br />I <br />CA <br />I hereby cenity that I flava prepared this rppiication and that the work will be done in Accordance with San itiaquin county ordinances, stats laws, and <br />nukes and rspulsoors of the Sar Joaqui`+ County <br />Hoe" owner or licensed aperit'r sipnawra Certifies the following: "I certify that in the pedormance of the wank far which this Peanut is At"Od, f "I not <br />altrrsplby any ptrrson a'r Wch mannar ar ta7 boctimA salblaa t to workman's corttpenaatton laws of California." Convactor's hiring or outs-rontractirg slgriature <br />cart -- taxa In Nom ". "I certify "MI in that parfasn%nea of the work tot which this psrtnit is ;*sued, t shall employ genera subject to workman's caavipasnAa- <br />tion boys of Crlifonnia.- <br />The applicant tali tot as inrpettions. Cornpi+ata drawing tar reverie sill. <br />t. -� .f <br />Signed X -a w� Title:_ I Data <br />..r FOR DEPARTMENT USE ONLY <br />Application A"apted by6 V4 <br />meta► _ Area <br />Pit of Grout Wooction by Date . Final Inspection by . «-~ Dates � 2-4 �3 <br />Additional Com awnis: <br />Apritcant - Return all copiea to; San Joaquin County Public Health Services <br />Environmental Hra.lth Permit/Services <br />445 N San Joaquin, P O Box 2039, Stkn, CA 9520 ✓�rL? <br />FEE <br />INFO AMOUNT DUE AMOUNT REMITTED CASHRECEIVED &V DATEEn <br />v iti 13-M tasv. t /a to 10-7 <br />tea ro•s6 <br />� s > <br />FA"' <br />