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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC AFAT•TH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009 , STOCKTON, CA 95201 <br /> l PERMIT EXPIRES I YEAR FROM DATE ISSUED •44✓- <br /> (Compiece in TrYPllcate) ' <br /> Application In hereby made to Sm Joaquin Country for a permit to construct and/or Lnarau the work herein described_ T <br /> application is made in compliance with Sao Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of St <br /> Joaquin County Public Health Services <br /> Job Address �� /�� city %l� Los Size/Acreage <br /> G1foCi��i+�• <br /> Owner s Name J.'t'JAddreas L 7 N Pc', 4%L r Ste. A - <br /> S t ,(-c ,97.x.7 <br /> Contractor '' �X/�LC' 'dress J4y'�� �f�C�.�-o­ <br /> 12License No/.-� 17�G''C_Pho e <br /> TYPE OF WELL/PUMP NEW WELLS WELL REPLACEMENT ❑ DESTRUCTION a Out of Service well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Q THER ❑ Monitoring Well <br /> DISTANCE TO NEAREST SEPTIC TANK Q'�r <br /> SEWER LINES<SO4r �tsi ��pOSAL� L�D�� PROP LINE r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> rNTENOED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r r-FwderMr+ei/7077►cam- 0 Open Bottom_ t7 Manteca Dra of Well Excavation Dra of Wed Casing _ <br /> f 1 DomessaclPrivate Gr6ravel Pack ❑ Tr y Type of Casing__ i'l/t' SIA yG Specifications <br /> f I Public I I Other elta Depth of Grout Seat Type of Grout" «, <br /> C <br /> 1 1 Irrigation 3�Approx Depth I I Eastern Surface Sent Installed by <br /> Repair Work Done U Type of Pump H P Stats Work Done_ <br /> Well Destruction ❑ WON Daarnster SeaLittg Material, i Depth <br /> Depth Tiller Material L Depth <br /> TYPE OF SEP WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo seplie system perAmiled of 04du c rawer as <br /> avadable vinthm 2001eet i <br /> Inatapataon wd1 Resrdenco Conurmarceaf_ Other <br /> Number of kvmg units Number of bedrooms <br /> Character of and to a depth o set Wats►tabls depth <br /> SEPTIC TANK ❑ Type! Capacity No. Campartnrnts <br /> PKG TREATMENT PLT ❑ Method of Odposat. <br /> Oistanme to nearest Weep F tion Propeny Luis <br /> LEACHING UNE ❑ No 6 Length of lines Total lengtn/sue <br /> FILTER BED to nearest ell tion Property Lets <br /> SEEPAGE PITS I I Depth $ into? <br /> SUMPS Ll to nearest Weft- Foundation_ Lms <br /> DISPOSAL PONDS <br /> I hereby certify that t haw prepared this application and that the work wap be dons in accordance welh San Joaglmm county ordnmances stat*laws, r <br /> rules and regufetaorn of the San Joaquin County <br /> Home owner or kcOfMW agsnt'a trgnature certifies the following 'I certify that In the performance of the work for which that pwaw is"owed I shop r <br /> empty any person in such runner as to became subAct tD workmen s compsnameon larva of California Contractors hrnng at sub-contraetang signattt <br /> certifa*s terve tc#cv nq I candy that-the pedorrnanee of ens Wort for which thea pervert is issued I shall employ persons eubfset to vrorkmen s compel, <br /> tion laws of California ' <br /> The applicant must cap for all squired inspections Complet*dmvvi mq loveSf}q side ` <br /> Signed ?( tie L•tJLiC G M da..o ✓� I J <br /> t*� Date. <br /> 1 1j <br /> FOR DEPARTMENT USE ONLY <br /> Appbeatwn Accepted by Data Area— <br /> i <br /> Pit or Grout Inspection by Date Final inspection by Date <br />. Additional Comrnants- �+ <br /> Applicant - Return all copies to San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N Sao Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERM" No <br /> EM a}HlralV ai4sa <br /> Eii t�.as <br />