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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br />. P 0 BOX 2009 , STOCKTON , CA 95201 <br /> PERMIT =IRES 1 YEAR- FROM DATE ISSUED /vl <br /> (Complete in Triplicaze) <br /> Application is hereby made to Sao Joaquin County for a permit to construct and/or irstaII the work herein described T~== <br /> application is made in compliance vitas San Joaquin County Ordinance No 549 and 1852 and the Rules and Regulatinns of San <br /> Joaquin County Public licalth Services L 17Z-4— <br /> job Address L.,2G /� �- C tv [.or SFze/Acreagefi/lei <br /> 7 <br /> /1 _ <br /> Owner a Name l l- r//-lir(/S Address - "~~ 14K Phone <br /> CantractaJC//'.+ii n �rrr-�' �r/r-e/Addresy7'`f� f/ -Y��'�J�n ��� License Noz�e277 0e Phone e3�;Z —5� <br /> TYPE OF WELL/PUMP .� NEW WELL fLr WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well C <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR LlOTHER ❑ monitoring well <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES �rgltl �/ DISPOSAL FLD PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> .INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i"""U l 11"VITprr �❑!Open Bottom ❑ Manteca Ota of Well Excavation, y` 'r Dia of Well Casing �- <br /> (1 OomestrclPrivate EI Gravel Pack ❑ Tracy Type of Casing.._ __ 17V� .7c/t�USpecrf+CiitonS <br /> I 1 Public ^f 1 Other P?Delta Death of Grout Seai — rl ,/ <br /> -- �r� Type of Grout�tr,•�i= <br /> I 1 frrrgauon -32 Approa Depth I I Eastern Suriaea Semi Installed by �/A� !�✓111LYV/T'� ire-jz6-- <br /> Repair Work Hone 0 Type of Pump H P State Work Done _ <br /> Well Destruction ❑ Woo D+amiater ung Material 4 Depth <br /> Depth Filler Material i Depth <br /> T F SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I 1 Wo septic system permitted if public sewer <br />• available within 200 feet 1 <br /> Installation„nil a Readertee, Conirnarcial_ Other <br /> Number of livrrtg urn's umber of bedrooms <br /> Character of $all to a depth of 3 feet table depth <br /> SEPTIC TANK 0 Type/Mf# Capacity No Comportments <br /> PKG TREATMENT PLT ❑ Method of Disposal <br /> Distance to nearest Well soon Property Line <br /> LEAC14ING LINE ❑ No & Length of lines �j�nqtWsize <br /> FILTER BED 13 Distance to at. Well Foundation Proptirtt Line <br /> SEEPAGE PITS Depth Sure Number <br /> SUMPS LI Distance to nearest WOO Foundation Property Lute <br /> D AL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work wiN be done in accordance with San Joaquin county ordinances, state laws on( <br /> rules and regulations of the San Joaquin Cottoty <br /> Home owner or licensed opera''@"nature certifies the following I caroty that to the performance of the work for which this permit a issued I shell no <br /> employ any person to such manner as to become subtect to workman s compensation law*of California Contractor s hffwv or sufscontrecting srgnatur. <br /> certifies the fc4ovmV I cernity that in the performance of the work for which this permit is issued,I shall employ persons sublect to workman s compenss <br /> non laws of California " <br /> The 4ap scant u U got so required inspections Complete �drawing ons ae side l <br /> Signed ►" r 1�r ��F--JL �tle1 �- Mie. � Ddta• 1 k <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Appineatwn Accepted by Date Area <br /> Pit or Grout inspection by Date Final Inspection by Data <br /> . AddrHonal Comments <br /> Applicant - Return all copies to SAO Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Hort 2009, Stkn. CA 95201 <br /> FEE MFq AMOUNT DdE AMOUNT REiMITTEO CASH RECEIVED By GATE PERMIT NO <br /> EH :3.24 tRIV ire%, <br /> EN tIMall <br />