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� J APPLICATION �k Wy <br /> SAN J QUIN count PUBLIC HEALTH SVVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �- 445 N SAN JOAQUIN,' PHONE (209)468-342 PA iWZjy-r <br /> P 0 BOX 2009, STOCKTON, CA 95201 E�vfd <br /> L IT BUIRES I YEAR FROM DATE ISS� <br /> !-P <br /> (Complete in Triplicate) SAN �� 3 <br /> Application is hereby sade,to San Joaquin Count for ��A (lig �. <br /> PUS Q r d C r w,-, <br /> County peruait to construct and/or � Cubed. This <br /> application is mode in casglisoce with San Joaquin County Ordinance No. 449 and 1862 asd <br /> Joaquin County Public Health Bervices. � of San <br /> Job Address 9so zi. SZ— City -XZd4-5� - Lot Size/Acreage <br /> Owner's Name .-1� ���L'T< Phone 1 <br /> Contractoq IAP-A-e Dlee AW., _Addres 04 ease ense No. Sys- <br /> / ? ? 3!y-Ss <br /> No. � � Phone <br /> PE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT rl DESTRUCTION t of Service Well <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROOLEM AREA CONSTRUCTION SPECIFICATIONS ti <br /> 0 Industrial O Open eottom O Manteca Dia. of Well Excavation Dia. of WON Casing <br /> Cl Domestic/Private O Gravel Psck >rTracy Type of Casing Specificatwis C r fe Yn <br /> I"I Public Cl Other I7 Delta Depth of Grout SealType of <br /> I i Inipation _Approx. Depth��I I Eastern Surface Soul Installed by <br /> ne <br /> New Work DoU Type of Pum � <br /> p G�IAH.P. Work Dam <br /> Wall Destruction O Wad Dianwter Rr 4e Sealing Material i Depth iT�' _P <br /> Depth ,/Z' Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/AOOITION 1 I DESTRUCTION I I (No septic system it public sewer is <br /> available wi het.! <br /> Inion a <br /> ce will sve: Residence_ Commercial,_ Other <br /> Numbs o!I Number of bedrooms <br /> Charat:tar of sof to a depth of 3 het: Water table depth <br /> SEPTIC TANK O Type/MfgNo. CwowVmnts <br /> PKG. TREATMENT PLT.OMethod of Disposal <br /> Dktsrta to newest: an Fowtdetion ' Line <br /> LEACH"UNE Cl No. 8 of fr>tm Total length/size <br /> Fi!TER SEO O to nNNW: Well Foundation Property Lite <br /> SEEPAGE PITS- I 1 Depth Size Numbs <br /> SUMPS LI Distance to nearest: Well Foundation Property Lite <br /> DISPOSAL PONOS O <br /> 1 hereby catOV that I have prepared 0*appieapon and that Me work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> rules and mWAstions of the San Joaquin County <br /> Home owner or licensed apoWs signature amfiies the following: "I certify that in the patormance of the work for which this permit is issued, I obeli not <br /> en icy any person in such manna ser to beeorne subject to workman's compensation laws of California."Contrsctoes hiring or sul"ontraeting sive fs <br /> A i1ies the follwair g:"I certify that in the performance of the work for which this permit is issued.I OW amploy persons wbjeet to workman's cornpenas- <br /> tion two of California." <br /> The applicant must cad for all bone. Cdrawing on reverse side. <br /> �'.� �:a�s ----Zi�` Titin: ®G/�✓ %� <br /> „1 FOR DEP RTMENT USE ONLY q <br /> Appfcetiort Accepted by � nate `2 <br /> Arne <br /> Pit or(trout Inspection by Dat. Final Inspection by tl oma 7 7 <br /> Additional Camm.nts: — <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Snvironsiental Health Persalt/Services <br /> 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE CASH DUE AMOUNT REMITTED INFOA H RECEIVED By DATE CK if PERMIT'NO. <br /> . En tea,IaEV.I/e3/ (0 s,14 I <br /> EN W30 <br />