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- APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV It JiS <br /> EN V I RONKENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 F E 3 2 2 <br /> P 0 BOX 2009, STOCKTON, CA 95201ENjIl ,�r1,; HEALTH <br /> PERMIT IRIS 1 YEAR FNN DATE tSSUEI���k�1 �f 3�F►�/���` ,�` <br /> (Complete in Triplicate) <br /> Application is hereby ends.to Sao Joaquin County for a perait to construct and/or install the vork herein described. This <br /> applieastlon is made in 00091iance vtth San Joaquin County Ordinance 10. $49 and 1862 and the Rules and Regulation* or San <br /> Joaquin County Public Health Services. <br /> Job Address _�� 6zC'g:__Meelle 1 /`a11� amity '417 Lot Size/Acreage <br /> Owner's Name 7 4 Address s1 f+- #S <br /> sFcft'p 414 1 <br /> Contractor.Aga eo6Cjdress L741 IU�S �O/OI�.• IDI License No. L 2:4!S�OW <br /> ` TYPE OR WELL/PUMP: NEW WELL O _ WELL REP CEMENT n DESTRUCTION O Out of Service Vali <br /> PUMP INSTALLATION O SYSTEM REPAIR O ILOTHER We p <br /> DISTANCE TO NEAREST: SEPTIC TANK .� SEWER LINES sof <br /> DISPOSAL FLO. PROP. LINEn <br /> FOUNDATION -3 AGRICULTURE WELL OTHER WELL PITW SUMPS = <br /> INTENDED USE TYPE OF WELL PWWLIEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial O Open dmtomO Manteca Dia. of Wal Excavation Dia. of was Casreg <br /> C1 0ornask/Private O (trawl Pack O Tracy Type of Caseq; Specifications <br /> I'1 Public R Other n Delta Depth of Grout Seal Type OILGrote <br /> 1 1 ""tion A Approx. Depth 1 I Eastern Sudsee Seri Installed by <br /> Repair Work Done L] Type of Pump H.P. Stab Work Done_ <br /> we$04MUFdon O WON Diarnster $rattan material i Depth <br /> S&L- j V444 S Pepth Till r Material A Depth <br /> TYPE 00 SURE WORK. INSTALLATION I i REPAIRIADOITION i i 06STRMTION 1 I INo septic $MGM permitted it public sower is <br /> available within 200 ha.l <br /> Installation VA snow: Contn+arciM_ Other <br /> Number of living;units: bedrooms <br /> Character of M11 to a depth of 3 het: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity_..._.. No. Comparsrnwrtes <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearva: WeE Foundation Property Line <br /> LEACHING UNE 0 No. i Length Total lengtiVsae <br /> FILTER $ED O distance to tsetse: Foundation Property Lina <br /> SEEPAGE PRS I 1 Depth Ss:. Number <br /> SUMPS LI Distance to we": Foundation Property Lina <br /> 018POSAL PONDS O <br /> I hareby csrWv dwt 1 hew prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stab Wi0ilric <br /> rules and gEtrletions of the San Joaquin County <br /> Homs owns►or licerwad agent's signature outiKes the fokwAV:11 cwfdy that in the performance of the work for which this permit is issued. I "no <br /> Mmp>oY srW parson in such mamm�er ss to baeoama subjset to woAemret's eor►►pMsatioA Iwvs of CalNornis."Conuaetors hiring a suat}eonaaetitmg ampniWre <br /> eMiRM the/oEovving:"i certify that in lima perfonnsnmee of the work for which thio permit is Wand <br /> 1 ahaa employ garcon subject to workman's oormpanmaa <br /> tion taws <br /> The fos ale Complete drawing on reverse,side. <br /> Siprwd Title: �...�tXXCes.1 lL,ua4a]L Dab: Z f J�_ <br /> EPARTMEft1T USE ONLY <br /> Application Accepted by , .tg.� Data Ana <br /> P'x or Grout Impaction by Oats Final Impaction by dab <br /> Additional Comments: +♦�r <br /> Applicant - Return all copies to: Sao Joaquin County Public Health Services owl(Do ayr <br /> gnviross:eotal Health Pernit/Services � � �� <br /> 445 N San Joaquin. P O Box 2009, Stka, CA 95201 <br /> AlMOIJOA re OtE AMOUNT IEM1PTE0 AECIVD iY EAMIT NO.CASH <br /> 93— <br /> aM 1M� <br />