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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 O BOK 2009, STOCKTON, CA 95201 <br /> PERMIT I;;gPIR}:S 1 YEAR FROld DA'Z'E IgSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Josqulc County for a permit to construct and/or install the worx herein described. This <br /> application is made Ir compliance with San Joaquin County Ordinance No. 5+4 and 1862 and the Rules [ural Regulatione of Sul <br /> Joaquin County Public Health Services. <br /> Job Address __= CC. .� ""`r`� ,ry�: ." �iL- L,--. Size/Acreage J <br /> � 7 <br /> _ dress Phone F- <br /> ` owner•.Name _ ---x--- <br /> s i� 7f i <br /> Contratltr_- -,i_ ense Na. .1 Phune <br /> TYPE OF WEL./ ,'NEW WELL WELL REPLACEMENT (. DESTRUCTION .���! but of Service Well Ct <br /> PUMP INSTALLATION C SYSTEM REPAIR G OTHER G Monitorira Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES -__— DISPOSAL rLD.__ PROP. LINE CKI= <br /> �1 -- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v <br /> .�' INTENDED USE TYPE OF WELL PROBLEM AREA CONST? . PION Sr--IFICAT!ONS v <br /> a Cl Industrial L Open Bottom Q Manteca Dia,of WONExcavation D a.of Well Casing <br /> rl Domaslic/Private Q Grovel Pack 1.1 Tracy 1'ype of Casing_ Specifications_ <br /> I.1 Ptsus: I i Other 11 Delia Depth.of Grout Seal _ —__- Type of Grow[ <br /> -- <br /> I I Irtigatton --kpjwox. Depth I I Eastern Surface Ss.l Installed by <br /> RepW Work Dons L] Type of Pump H P. —_ State Work DCre_. . <br /> WON DealruCltpn CJ Well Diameterhealing Itaterlal L Depth <br /> Depth_- /Tiller Material 6 Dcpth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION REPAIRIADDITIOP4 i I DESTRUCTION I (Nn septic system permitted J public sower is <br /> avadabLa wnl',in 200 fnt.l <br /> IMtal4lion wiN serve.,serve., nu Co, other O--- �F CU s-*t 1�P1+r Y• �y�j psir 1 <br /> Number it Irving unit,:R rt be <br /> y <br /> Chatactar of sew to o depth of -�� -Waren table depth_ <br /> FNTIC TANK O Ty, (_." r �_ Cawtcity- SX- '_6 No. Compartments <br /> PK6, TREATMENT PLT.n Method of Disposai <br /> i WallV__(,l Foundation_�— Property Line_ <br /> i LEACHING LINk. _ No. Length of Imes ---1� -mac --_ Tnial length/.is <br /> FILTER BED _i Distance to nearest: W.II Founuat on _ Propenh <br /> 7 SEEPAGE PITS 1 Depth ��Stn <br /> a SVM►S LI Distance to newest: Well.,,QQ Foundation Properry Line <br /> EjR DISPOSAL PONDS O V <br /> -y t hateby eMhtV that 1 have propatgd this app4,caUon and that the work will be done to accordance with San Joaquin county ordinances.state laws, and <br /> u <br /> ]i rnts"nguMtwis of the San Joaquin county <br /> I/Orth Ttwnar a licensed apent's signature certifies Lha fotawing:"I candy that in the pmformance of the work for which this perrrwi it,issued,I shall nor <br /> enplo'y any person in touch monnar s&W become&ubiect to workman's compensation Laws of California."Contractor's hiring or sub-contracting signature <br /> S CWdsis the toaowvp:"I cortity that in the Woimance of the work for which this perrrut is issued.I&hail employ porsons subject to workman's comports <br /> tion lerwo of Casltornlo." <br /> The app4can�caM for M r ed in s. Complete dna on reverse side. <br /> 4 <br /> Signal <br /> FOR ARTMZNT USE ONLY ((�� c, <br /> lbn Atcepted DY 1 "� _ _ <br /> Data �T-V+ ' Area �- t•.- 'N. <br /> .{ Q <br /> E rout Inspection by t at�� rinse Inspection by cx r Dar. <br /> s iJ/ddltlonal Cawtwns: <br /> Applicant - 8eturo all copier to: San Jo-Quin County -blic Health Services <br /> Fsvlronnental Noalth Per%t/Services <br /> 4a5 N San Joaquln, P U Box 100u. St CA CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED KRECEIVED 7Y DATE PEFMrt NO <br /> WFO CASH <br /> .tor.ICU tRty,irasi ' {,o-� / <br /> A <br /> r <br />