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_fj( <br /> i SAN JOAQUIN COUNTY PUkLIC HEALTH SERVICE rell�tq <br /> r(aX��L �' ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQU IN, PHONE (209)468-3420 <br /> P -0 BOX 2009, STOCKTON, CA 95201 <br /> CPERIIIIT E$PIRE5 I CHAR FROM 4A' ISSUES <br /> (Complete in Triplicate) <br /> Application is hereby sate to Box Joaquin County for a permit to construct and/or install the vork herein described. This <br /> epplleatioe to road* in eort+lianca vlth BAn JOAQVin County Ordinantd No, 544 end 1662 and the ules end Regulations of Ban <br /> Jot,4vin County Nblic Health Services, <br /> Job Addree## U 3 dC/f!G 14 vel,I/-c- C• y SI'PC N Lot ul /Acrcage <br /> Cv�SVlr�ro ep�rh/IeA rri.yi.crr✓�..�� a S��/ 3�w 1. e-/ s-J V fizz te.��✓ rY g 5-�-� <br /> Owner's Nemo eel Addrb&s "0 43� � 4 Phone j.—/D 772 3 <br /> 9 S! <br /> Cor,l+8ctor �+'V a to !/✓• Irl Addtess Pe G y �Jn�s Llcens! No.�S7 72rZ jpnone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 71 DESTRUCT ON that of Gervice Well <br /> 1I PUMP INSTALLATION ❑ SYSTEM REPAIR M OT ER ❑ Monitoring Well C] <br /> 01STANCE TO NtAAEST_! SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS J <br /> INTENDED USE E TYPE OF WELL PRDBLEM AREA CONSTpUCTION SPECIFICATIONS W <br /> (,I tnduetNal open Bottom ❑ Manteca De. of Well EXCevatiOn DID. of Welt Casing <br /> vDomestic/Privats! C1 Grwdt Pack' D Tracy Type of Casing_. Specifications <br /> 1-I Puhtic 1:1 other 171 Delta Depth of Grout goal Typo of Grout <br /> 1 r Irrlustlon -'7J- Aptwdu, Deplh I I Eastern SurlAc# Saul Installed by <br /> Repair Work Cone U TY0 of Pump H.P, State Work Dons <br /> Welt Destruction Well Diameter 7healing Material • Depth -f-� <br /> filler ftatarial i Depth <br /> TYPE OF SEPIK: WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I tNo septic •y lam permined If public rawer 1s 11 <br /> II /vIlilable with n 20L1 feel.) <br /> Initallatlon will serve: Flaefdenof- Commercial Other <br /> Nurnb/r of living dnitS: Number of <br /> Character of Solt to a depth of 9 feat: EXP[rRi-Elywater ,FfwRMT ble. depth <br /> SEPTIC TANK 0 Typawf0 Capacity tl�4i/ No. CO partrnante' <br /> PKt3. TREATMENT 00, Cl Permit may have expired Without Method of Dispoeet <br /> Disibnce to near*Z,�o�'kl li��A71Q(L� F�ropertY Lins <br /> LEACHINd LINE L1 No, A Length of Ilh Y `nvfrOn M-: � LrLGlenpthJslre <br /> FILTER BED (l Diettince to nearAtt: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Site Number <br /> SUMPS L1 Distinct to neafest: Welt Foundation Property tins <br /> DISPOSAL PONOS ❑ <br /> I hereby certify 0181 f have prepared thle sppticatioh and that the work will be done in 6CCOtdenCe with Sen Joacti An county ordinances, stets laws, and <br /> rules and mquteilonl of the $An Joaquin County <br /> Home owner or Ilcar;eed ageht's iIpnalur6 mrilfles the following: "I t;erlify that in the porformance of the work for which this p6rmil Is Issued, I shall not <br /> employ any person In Such rrtehn*r it to becrxns tube o workman't compensation Iswi of Celliornia." Contract is hiring or tub-Conpecling slgnatute <br /> carlllise tho following: "1 c6rtify that In the perdorrnanc o the work for Which thls'petmlt Is issued, i$hall amploy Pe-&ohs subject to wofitmen's com nta <br /> Ilan teat Of CA1lfornI P (�-� (- <br /> The applicant must Cat) tot all ►eVuif Clt o its side. <br /> Signed y Title: Gisrr�✓ Cn i ra (a Ca� / t Ost6: 9�` <br /> ✓ P,2 �i Y l r /!J D2 S-/U S <br /> FOR VFPAATMENT USE ONLY <br /> Application ACCepteIi by Date `Zt ?� Area i <br /> Pit or Grout Inapeetlton by 'D� bath Fina! Inlp6ction by Date .� <br /> Additional Commanta: LM-5 ��"�' C � <br /> Applicant - Return all copies ta: an Joaquin Coubty public Health Ser v ei7 <br /> &tvf*votnental keulth Permit/Services <br /> 446 N Dae Jaaquih, P O Box 2009, Stkn, CA 96201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K litCli BY DA E PERMIT'NO �c <br /> INFO f �( �CAS <br /> /H / .f �7 '72-42-1-d <br /> tN13.»iflev.r.al5r td � (p[J 1 l,�f l 9 y [• �� <br /> rrs,4.x <br /> � 71 <br />