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APPLICATION <br /> t <br /> SAN �J ?AQUIN COUNTY PUBLIC HEALTH �MVICES <br /> ENVIRONUMAL HEALTH DiVISION <br /> 445 N SAN JOAQUIN, PHONE d09)468-3420 <br /> P 0 BOX 2009, STOCXTON, JCA 95201 rr-;, <br /> r :a -'J <br /> EXPIRES I � Z �,L <br /> P—MIT YEAR- FR UEDA mFl <br /> All ISS <br /> (CompleteisTripliclate) <br /> Application is herby made to San Joaquin County for a permit to construct and/or inxtall-the!vark hek;e-ln <br /> is ­ciesci� bed: T�16 <br /> appllcatioa made In COMP218XIce with San Joaquin County Ordinance go. and 1862 and -th" 'Rules.and Hegulaticns of Ban <br /> Joaquin County Public Health Services. <br /> 11273 E. Ada Ave. <br /> Job Address city Stockton Wt Size/Acreage <br /> Services 1� <br /> Owner's Name Sierra—Bay Farm Cred ress P.O. Box 8070 Stockton Phone(2 0 9 531 -37701 <br /> Contractor Spectrum Address 2825 E. Myrtle St. i�. License No. 512268 phone 465-8712 <br /> TYPE OF WELL/PUMP: NEW WELL C] WELL REPLACEMENT L-lE DESTRUCTION C3 Out of Service WelX 0 <br /> PUMP INSTALLATION C3 SYSTEM REPAIR 01 OTHER 2Soi Ir V1t0Bor3,r1Z41 Wengll [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO.— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROS LEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open Bottom 0 Manteca Dia. of Wail Excave"lich. Dia. of Well Casing <br /> I"1 Domestic/Private C3 Gravel Pack 0 Tracy Type of Casing — Specifications <br /> 1*1 Public n other n Delta Depth of Grout Seai — Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done U Type at Pump H.P. .11 State Work cans, <br /> Well Destruction 0 Well Diameter Sealing material & Depth 11 <br /> Depth 711ler Material & Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/AOOITION I I DESTRUCTION I I lNo segfic system permitted it public sewer is <br /> available within 200 lost.) <br /> Installation will serve. Residence— Commercial— Other <br /> Number of living units.— Number of bedrooms <br /> Character of sad to a depth of 3 feet: <br /> Water table depth 7 <br /> SEPTIC TANK. 0 Type/Mfg Capacity-- No. Compartments <br /> PKG. TREATMENT PLT.[3 Method of Disposal <br /> Distance to nearest: Well Foundation Property Una <br /> LEACHING LINE C1 No. & Length of tines Total length/size r <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Una <br /> II <br /> SEEPAGE PITS I I Dit-2th _—Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county oedinances, state laws, and <br /> rules and regulations of the San Joaquin County ,il <br /> Home owner or licensed agent's signature certifies the fattowing: "I certify that in the performance of the work for which this permit is imed. I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Coniractor's hiring or sub-contraicting signature <br /> certifies the following:"I certify that in the p4doemance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applies mus call for allrequired i Complete drawing on reverse side. <br /> a�,ns tions.ns. <br /> AV <br /> Signed Title: , Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Are, �2 <br /> Pit or Grout Inspection by rte Final Inspection by Oats <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009,6 Stkn, CA 93201 <br /> FEF <br /> INFO CAAMOUNT DuE AMOUNT REMITTED CX Ji 'RECEIV-io 911 DATE PERM.IT'NO. <br /> SH � <br /> L4:3-24(REV.11$1 it <br /> EM 4-V <br />