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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ' ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> RWMIT EXPIRES 1XEAR F T I S <br /> 1 <br /> e in- Triplicate) <br /> ate)is <br /> (Complete p <br /> Application in hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in am%iliance pith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Connty Public <br /> cc]Health Services. <br /> • City i' Lot Size/Acreage L.. <br /> Job Address k <br /> �, p r J! rF l I <br /> Owners Name WI�bUI" " L1!LS Address ?1 - hr us 1 VQL Phone Z <br /> 1 tD[�y�s3�f <br /> Contrattor Address Z$ icense No. o/ Phone <br /> TYPE OF WELLIPUMP: NEW WELIt❑ WELL REPLACEMENT n .. DESTRUCTION E1 Out-of Service Well ❑ ! <br /> PUMPINSTALLATIONX1 ,�ttts!?,.� `%SYSTE�ii REPAIR ❑ �, OTHER D Monitoring Well C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPQ�'SAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I <br /> 'TYPE-OF-WELL-- ROBLEM-AREA-�---GONSTRUGT40N-SPECIFIGATEONS <br /> Cl Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation — Dia. of Weil Casing I <br /> C1 Dorn 011Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ; <br /> (A.Public: fl Other n Delta Depth of Grout Seal Type of Grout \ <br /> [I i Irrigation �.Approx. h I I Eastern,_.,., tate_ Surface Said Installed.by <br /> ��,,�y H.p. ! SWork Dene <br /> Relkair Work Done 0 TYPO of f ump lei gl�' ` 1 i <br /> 'Weil Destruction 0 Well Diameter 1 Sealing Material i Depth <br /> t Depth f Filler Material i Depth + `., <br /> jTYPE OF.SEPTIC WORK: NEW INSTALLATION I I REPAIRIAOOITION l I DESTRUCTION i I (No septic system permitted if public sower is <br /> 1 avtiilable within 200 feet.) <br /> i <br /> InitalFation wilt serve: Residence— Commercial Other P�YME ,� f <br /> j ' <br /> I F Number of living units: Number of bedrooms, <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg , capacity— <br /> I.. "foil <br /> i PKG. TREATMENT PLT.❑ <br /> t rll Distance to nearest: Well Foundation Prr eR#yJOtlVd1i TIN CCISNTY E <br /> r t+ <br /> LIC PUBLT',1 SERVICCS <br /> r ;_:� „ Tota�lU�i PnW 1 A L ALI M I 5r I <br /> OACF WG LINE Cl No':6 Lenoth of lines <br /> FILTER BED n Distance to nearest: Wall. Foundation Propeny line <br /> SEEPAGE PITS -e� I I Depth Size r� r rNumber [ <br /> SUfNPS , LI Distance to rlaaroat: Well N •0ioundation Prdperty Line t <br /> 'DISPOSAL PONDS h" 0 `;r'' ." <br /> '0 hdraby cenify that I hive prepared this application and-that the work will be done in accordance with;An Joaquin county ordinances,state laws, and <br /> rulss and regulations of the San Joaquin County t <br /> (Home owner or licensed agent's slgnsture eertifis$the follo"6: "I certify that in the performancR of the work for which this permit is issued,I shall not <br /> }employ any person M such manner as to become subject to workman's compensation laws of Ga4ifornia."Contractor's hiring or sub contracting signature r <br /> certifies the following:•I certify that in the pedormence of 1he work for which this permit is issued. I shall employ persons subject to workman's compensa- <br /> tionColnlaws of la: If ti <br /> The apptic st c r 'rrgquired insp"i a. Complata drawing o reverse-s[deS 1'k 2 <br /> SignedDace: <br /> Title: ,.s j � . <br /> k t OR ARTM USE ONLY ' ! <br /> Application At cepted by + 'i iDete ;Pl1:4wres <br /> I ") r <br /> Pit or tirout�nipectTtin'liy <br /> Date final Inspection by <br /> l �1dd1110M1 ttirnrnants: '�� `^-1 �� i <br /> + Applicant - Return all copies to: San 3ftquin'0bu6ty Public Health-services <br /> 1 Environmental Health Permit/Services <br /> E�E 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> I i f <br /> t FEE AMOUNT DUE AMOUNT REMITTED IleCASH RECEIVE BY DATE PERMIT'NO. <br /> 3.1i Mev.I/N alINiO &LIL 7 <br /> I:H[,?8 <br />