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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC SEAT TH S - <br /> ENVIRONMENTAL HEALTH DIVISI <br /> 445 N SAN JOAQUIN, PHONE (209)46 -312[} <br /> 0 <br /> P Q SOK 2009, STOCKTON, CA 9511`';; #,c <br /> S 1 <br /> YEM LROMD �§aU1� <br /> (Complete in Triplicate) _ _:J <br /> Application is hereby mads to San Joaquin County for a permit to construct and/or lnatell the vork herein described_ This <br /> di nc L9 and i W amd the Rut a d Ac tions f San <br /> applicRtioa is rt►tde is compliance with Ban Joaquin County drna e H o 5 8 8t?�� -7 <br /> Joaquin County� ftblie Ifeelth Services. Q�} <br /> /p14 <br /> JobAddret P&O. 1, /, 1)6 0,4k --r't[� -- City Lot SSte/Acrerge L�1{ <br /> Owner's Name ss !r'- -� - _... phone <br />' Contractor_ Ak:�Vddrest +� LiN"37,4,70 phone <br /> TYPE OF WflllPIJMA: INEW WELL WELL REPLACEMENT C1 DESTRUCTION D out of Service Well Q <br /> PUMP INSTALLATION Q SYSTEM AEPAIR U OTHER ❑ Monitoring Well L] <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL rLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENOED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L_1 industrial ❑ Open Bottom 0 Manteca Dia. of Well 1Ex0avati0 Dia. of Weil Casing d <br /> [I Domestic/Private 0 Gravel Pack 0 Tracy Type o1 Casing Specifications <br /> fl Public 1-1 Other n Delia Depth of Grout Seal Type of Grout <br /> r atron _Approx. Depth i I Eastern SuHace Seel Installed by edvii&4c it <br /> +Repair Work Done L7 Type of Purrnp H.P. _ Stan Wadi Done <br /> Well Destruction O Wall Diameter Sealing Material a Depth <br /> Oeptfr <br /> Filler Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITtON I ! DESTRUCTION I I INo septic system perrooted II public sewer is <br /> available within 200 feat.) e <br /> Installation will serve: Ra0dence T Commercial— Omar fl. <br /> Number of living units: Number of bedrooms '1 <br /> Character of soil to a depth of 3 fest: Water table depth a <br /> SEPTIC TANK ❑ Type/Mfg _ Capacity <br /> PKG. TF1fJ1TMEWT PLT,Cl �� rpaonnz: <br /> f <br /> Distance to nosiest: Well Foundation <br /> LEAC"ING LINE C1 No_ & Length of fines <br /> FILTER BED F1 Distance to nearest: Well Founcatia PUBl1��Ei4Y�{� <br /> NLMENT <br /> SEEPAGE PITS I I Depth Size Number. <br /> SUMPS Lt Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> t hereby certify that I have prepared chis application and that rhe work wilt be done in accordance with San Joaquin county ordinances, state Laws, and <br /> rules and regulations of?he San Joaquin County <br /> Home owner or ficensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall not <br /> employ any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sul�-contrecting signature <br /> C61131"the fallowing:"I certify that In the perfom►ance at rhe work for which this perrrtir is issued,1 ahaii employ persons subject to workmen's eompenea- <br /> tion laws of Cawornla." <br /> The applies ust call all required inspection Comptete drawing on reverse to e_ <br /> Signed x - Title; Date:+J <br /> FOR DEPARTMENT USE ONLY <br /> (L. v <br /> rApplication Accepted by - - - Date -7r Area �. <br /> Pit or Grout tnspeotion by Date Final Inspection by Data <br /> Additional Comments: g "/ <br /> Applican\ Return all copies to: San Joaquin County Public Health Services <br /> + Sovironmental Health Permit/Service$ <br /> 445 H San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT OtM AMOUNT REMITTEDCASK RECEIVED BV DATE PEAMIT'N4. <br /> IN€GS <br /> • EfMr 11 <br /> 4,31 tAEV.i r n pr ! S V 1f 1 .360--J <br />