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A211LICATION FOR PERLIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL IiF.ALTII DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O Box 2009, STOCKTON_ CA 95201 <br /> pERX T EXPIRES i YEAR.FRQXDA_TF ISSUED <br /> (Compl(?te in Triplicat^) <br /> Application is hereby made to San Joaquic coun•y for a permit to construct and/or Install the vork herein described. T1116 <br /> tyyllcatloo is Fade 1n catjVllan�e with San Joaquin County c.:dinar,ce yo. 5'19 and 1862 a.•id the Rules and FegulatlOne of San <br /> Joaquin County Public Health oervlcer. <br /> o? S�3:z3_ City'4c— — _ <br /> Job Address -- �" Phone <br /> Owner's Name Add,.%% __S_�— <br /> 121;1/ Phone <br /> / r+ �____-__Add•r11_c� L,tenle N <br /> contractor_ <br /> TYPE OF WELL/PUMP NEW WELL 7 WELL REPLACEMENT fl DESTRUCTION ❑ Out of 9ervi e• Yall Cl <br /> _ Monitoring Well C <br /> PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER O <br /> DISTANCE TONEAREST: SEP1iC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> PITS/SUMPS _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> b LI IndOauial 0 Own Bottom O Manteca Da of Well Escayston Ora. of WOII Casing <br /> Specifications <br /> v C1 Domestc/Privet• Cl Gravel Pack n Tracy Type of Casing__ -- \ <br /> 1'I Public fl Other i'1 Delta Deptn of Grout Seal — Type of Gfovt -- <br /> f I I titillation _Appro-. Dopa ! I Eastern Surface Saul Installed bypvcm (t, <br /> f __ __. Stats Work Done_ W <br /> Well ecruwnrDons L Type i Pump _._ healing Material b Dmpth <br /> R <br /> Well Da•tnxtron ❑ lYeb Diameter _ J, <br /> Depth Filter Material a D1,th U] <br /> • TYFE OF$EP11C WORK. NEW INSTALLATION! I REPAIR:ADDITIJN DESTRUCTION I (No sept,[system par mdtad d p,ibfic SOWW is <br /> AI [' avadabie witMn 2011 feel.) <br /> r. Inats"non vvd serveResidence_ Comnrorcd v Other, C ej L1_C�- C ti <br /> Nurnp•r of le,--g units: __ NJmher of bedrooms <br /> Water table depth <br /> Chvacm of Fos to•depth of 1 feet:_.L` _— L� <br /> SEPTIC TANK P- Type/Mfg o)tG �_��-- C.—,c; No. Comoartmenn <br /> C <br /> PKG.TREATMENT PLT.Cl Method of Disposal <br /> Distance to nearest: Well Fou{n�datrn_(yc_ PropeAv lino_ <br /> Total Mr. thisae <br /> LEACHING LINE �No b Lend m of stns _ __ r 9 -'c <br /> PATER BED F.a' Distance to neerest: 'Neu_ <br /> 7O Fourwattcn P:ooerty Lino � <br /> SEEPAGE PITS tr#�Oepth Size- 3 6 Number•_ <br /> _ SUMPS LI Distant,to nw•at' Was /70_ Foundation A: r <br /> / P.opev lino 1 <br /> DISPOSAL PONOS ❑ <br /> ed that Ota work will be done accoruance with San Joaquin county ordinances,state tows,a <br /> I t+areby tar.maty that 1 new prepared dm applrcnan send <br /> M <br /> mi"end rmpAstiona Of the San Joaquin County <br /> _ Homs owner or IicanaW agent's sigrvturo eMif�es the fetlOw"ng' "t certify that in the peAormsnu of �,s work for which thio wrr,nt u•uu•d.I v sH not <br /> enlpioy any person x,Duch nw v as to bocome aubFect to workman's compensation laws Of California."Contractor's hiring of cub.contractin7 Ygnatuff <br /> grtifiee the loanwing:"1 c•rt+fy that in(he prtormance of the work for which this permit is issued,I shall employ pefsons subtoct to workman's componsa. <br /> Son wrs of csdor,".- <br /> -,. The coOtM roma M utr inspocttona. Completnw <br /> ta drswg on faaverside. <br /> Signal <br /> Tisk Dnr � e <br /> r a DEPARTMENT USE ONLY <br /> Dan <br /> 4�—FOR <br /> '[�•' AreaAppHctia+sAccepay by __ / <br /> ate_- Fin I Inspection y ,�[4Gf1-�-. D • �f �� <br /> PH tt O:out Inspection by // � � f <br /> P <br /> iACQhJonNComm.: <br /> Cos• <br /> Applicant - Return all coptee to: San Joaquin County Public Health Fervlres <br /> Enviromnen tit/ Health rel,mit/Services <br /> 4 4 N San Joaquin, P O Box 9000. Stkn, CA 95201 <br /> FEE AMOUNT DILE AVOUNT Rf MIT ED -_ ECfivt SY O TE �ERMC'NJ. <br /> INFO <br /> tiN tary ,,.,i;]Jl' I—//�',.e-o (/Y'°Q/ ✓J'=� i�d .,d" !.� ✓ C/_,, , <br /> Ek 14 X rC_- j <br /> �J <br /> ,ow <br /> •Fa� <br /> . I <br />