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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> TNVIRONMHNTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERE[ EXPIRES 1 YEAR FROM DA E S IIID •%Ii✓- <br /> � ri-f W <br /> ( Comniete in Triplicate) <br /> Application is hereby made to Sam Joaquin County ror a permit to construct and/or Install the vorlc herein described T`ic <br /> applicatlon is made in co=Pliance vlth San Joaquin County 9rdlnance No 549 and 1862 and the Rules and Regulation of San <br /> .70011111m County Public Health Services <br /> JoO Address �%�� "/ / -Z 1��_ C tv /✓ Lot Size/Acreage <br /> Owner a Name J��r(Address J L1 37 -J Peen.A ->-A,.,L -A� 4--e— A <br /> ---��� <br /> Contractor /i�'/ULI�' _�?U�GC-,t'i1�jy�(ddress d�� <br /> " ^ � License No/_•G'��7ZG�PhoneGaC—1✓S <br /> TYPE OF WELLIPUMP NEW WFLL,2- WELL REPLACEMENT n DESTRUCTION 0 Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C]� THER C3 Monitoring Well <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES� 0'4, -iw-3 U15POSAL FLD PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ;^ %TCN./T/, ❑ Open Bottom ❑ Manteca Die of well Excavation <br /> Dia of Well Casing Z <br /> .(I DomesticlPrivate 01Gravel Pack' C1 Tr y Type of Casing_ �rl/C' Sr s. •YC7 5pecificanons <br /> I I Public <br /> I] other alta Depth of Gaut Seal ��" Type of Grout - <br /> InrUauan -i Approx Depth I I Eastern Surface Seel Installed by w W r <br /> Repair Work Done U Type of Pump H P State Work Done _ <br /> Well Destruction ❑ Well Diameter Seallmg Material & Depth <br /> Depth YtUer Material A Depth <br /> TYPE OF SEP WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 i INo septic system pernafted d publre sever is <br /> evadable within Bet 1 <br /> Inatallarwn will w Rasrdenee, Comniarcial, Other <br /> Number of kvirig wets Number of bedrooms Ifs <br /> Character of sod to a depth o Bae. water[able depth <br /> SEPTIC TANK ❑ Type/ CaPacnY <br /> PKG TREATMENT PLT ❑ NO Compaitnienn f <br /> Method of Disposal <br /> Distance to nearest Well ;:F� anon_ Property Line <br /> LEACHING LINE ❑ No A Length of Imes Total length/size <br /> FILTER BED ❑ Distance to nearest all �—�Ant-on <br /> _�� Property Line <br /> SEEPAGE PITS I I Depth Sue <br /> mbar <br /> SUMPS LI to nearest WON — Foundation <br /> DISPOSAL PONDS Line�--- <br /> I hereby certify that I have prepared this application and that the work wry be done m accordance with San J <br /> rules and regylatioru of Iha San Joaquin County oaqun county ordnances, stair Inuits and <br /> Home owner a1 licensed agent a agmture cernffts the f0dowrng I certdy that in the pelfai P nce of the work for which the <br /> smploy any person in such marmot,as to become subjectpertram is issued. I shelf not <br /> certifies the f 1 to workman f a coi►ipthis iorr laws of California Contractor's hirmg at swbcontraetng signature <br /> tion lows of Califonw cOrd/y that a7 tits Performance of lite work far vwhteh this pernat n ieauW I shall employ persons subject to woo man a compon". <br /> The epPhcant must call for an required inspections Compete des <br /> v^^g Dr+ rove Ssal side <br /> �. �w (+ fid'=! <br /> Signed x : j"�1.,���_, �-• ... t�4 e c a.�.+a� Date- i t S <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Aires <br /> Pit or Grout Inspection by Data <br /> -�� Final Impaction by Date <br /> Additional Con7ments <br /> Applicant - Return all copies to San Joaquin County Public Health Services <br /> Eaviroamant:al Health Permit/Services <br /> 443 R San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> =EE AMOUNT OUti AMOUNT REMITTED K <br /> iNfO CASH RECEIVED NY DATE PERMIT NO <br /> . EM 13-24 MEW ir,isr <br /> E+i Iasi <br />