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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLICL)M420 <br /> ENVIRONMENTAL HEALTH DI 445 N SAN JOAQIIIN, PHONE (20 P O BO% 2009, STOCKTON, CPMUIT EXPIRES 1 M <br /> (Complete in Triplica Application i■ hereby madeto Ban Joaquin County for a permit to construct snapplication ie mode in actiglience with Baa Joaquin County Ordinance No. 5219 as and Regulations of Sen <br /> Joaquin County Public Health Services. E <br /> Job Address 123 7( Fr AZ Z flf r !//l! l/ City L )))1 � E'rl LOT Size <br /> �t�¢i /{�e !/L(!.'W ��Llan one 471 —.3 <br /> Owns;a Neme y address <br /> Contactor 1 `t' E02 .r Address }1__._ (! License No. Pnone 4'�J << <br /> TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT F. DESTRUCTION 0 Out of Service ala 0 <br /> PtAMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES DISPOSAL FLO. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS. <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom ❑ Manteca Dia. of Wen Excavation Die. of Well Casing <br /> C1 Dom"ic/Pr'wate 0 Gravel Pack7 0 Tracy Type of Casing Specifications <br /> j•I Pu34C 1-7 Other fl Deiiia Depth of Grout Seal Type at Grout <br /> 11 ImitpMlon —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Dom U Type of Pump H.P. _ State Work Dora_ W <br /> Wall Daahuction 0 We"Diameter Sealing Material a Depth <br /> Depth Piller Material a Depth <br /> 7YPps�nF SEPTE^C'WOgK: NEW 1NSTALLA ION I 1 EPAIR/ADDITION I I DESTRUCTION I 1 IN septic sYsts 'f grblic u <br /> Mfiort vela ]W —� 7L A aysilabls wit Mt.l <br /> In e C « 1 T� C6mmerold,Y_ Other <br /> Nurnbef of Evi^g undo: _ Number of bedrooms <br /> Character of son to a depth of 3 teat: We r table depth <br /> SEPTIC TANK 0 Type/Mfg C+Vecity Nn CortpaRmena <br /> PKG.TREATMENT PLT.0 M thod of Depose! Nly <br /> Distance to ntaatasL Well Foundation Props Line <br /> LEACHING LINE 0 No, 8 Length of Teas _ Total length/a' s <br /> FILTER BED 0 Distance to neereat: Wall Foundation _ Pf Lkte <br /> l ' <br /> SEEPAGE PITS I I Depth _Sue Number <br /> SUMPS LI Distance to serest: WON Foundation Propsn Lire Jt <br /> DISPOSAL PONDS 0 <br /> I Mreby,comity that I he"prepared this application and that the work will be done in accordance with San quip county ordinallces, ata laws, and <br /> rules and regulations of the San Josqu;n County <br /> Hens owner or licensed agent's ygn»+urs ceniMe 7th lollowing: '"I certify that in IM performance of the work whim thin permit' issued, !shell r <br /> employ any person in such manner ria 10 became subject Io Workman's compansalion laws o�.0 bfwl ' hiring or sub-compacting fi alum <br /> to? <br /> unifies the lollowing: "I certify that in the performance Of the Work for which this permit is issued, I shall employ ps bjeci to work/man's mpensa <br /> tion Owe of CalifoI "it C Q 6ao <br /> The epplic t tall for OR�?10,,ta.,ue/dim{ coons. Complete drawing on averse aid J fl <br /> Signed m' /-1.,L.Ff Tids: rl Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date / 7l Area isol <br /> Pit or Grout Inspection by Dace N Inspection by Da» <br /> Adoicial Comments: .2����'�s r-:0&4 1 l ' s <br /> Applicant - Return all copies to: San Joaquin County Pu c Ha41th Services <br /> Environmental Health Permit/Services �� <br /> 495 N San Joaquin, P O Box 2009, Stkn, CA 95201dw y <br /> Ljj_ NFO AMOUNT DUE AMOUNT REMITTED '" H REWEO 9Y CEDATE PERMIT NO. <br /> E. -24 lary <br /> fN 1l]a <br />