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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t <br /> ENVIRONILKNTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> r <br /> P O BOX 2009, STOCKTON, CF, 95201 <br /> DIRES 1 YEAR FRlIY name T ett�n <br /> (Complete in Triplicate) <br /> Application is hereby Bode to San Joaquin county for a permit to construct and/or install the work herein described. This <br /> ts� _ application is side in coeipliance vlth Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> - Joaquin County Public Health Services. <br /> Joo Address /SLG7 $-, ST/ENrSGLIL /2 y7 Coy-"C-44' Lot Size, cre e <br /> s Owner's Name T) 7, CtA TIDh/ Address 1S-lAQ S SnE.�/ �L /2D Phone <br /> Contracts FLeryD LSA/1�vg,�_Address 7 rt1' ilDis? - �r License NO. Phone z`Sf <br /> TYPE OF WELL/PUMP. NEW WELL U WELL REPLACEMENT Ci DESTRUCTION Cl Out of Service well ; <br /> PUMP INSTALLATION O SYSTEM REPAIR [; OTHER C Monitoring Well Q <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _, ? <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 <br /> -' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Industrial O Open Bottom ❑Manteca Dia. of Well Excavation _ Dia, of Well Casing <br /> (1 Domestic/Private Cl Grx%*Pack l] Tracy Type of Casing___,_ Specification: In <br /> Prblc 17 Other 11 Dehio Depth of Grout Seat Type of Grout <br /> 1 I IrnOalion Approx. Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H P._ State Work Done {� <br /> r; \1 <br /> Well Destruet•an 0 Well Diameter Sealing Nat.rial A Depth <br /> i Depth Filler Mate•ial L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system pwmuud it public sower is <br /> n_ <br /> Insullatlon will serve: available within 200 foot.)rve: Residence'�Commercial� Other <br /> Number of fiving units: /7)0�81Lf �ilff y/ <br /> � Number of bedrooms <br /> Character of sole to a depth of 3 foot: _.Tie✓D V Lo.o _ Wanr <br /> SEPTIC TANK O Type/Mfg tebM depth (\_ <br /> —��- Capacity l 2.0o No. Compartments 2 <br /> ST t1 PKG. TREATMENT PLT.O <br /> Method of Diaposal yr <br /> { <br /> Distance to nearest: Well \ <br /> .,.>3L'C.� Foundation._'� Property Line /DI� \� <br /> - LEACHINr3 LINE Lala No. 8 Length o1 lines _ - 'SS r <br /> Totallenpm/airs //d <br /> FILTER BED ❑ Distance to nearest: Weil AW Foundation /e Property Lk-,@ ai \ <br /> SEEPAGE PITS 1� 1 Depth .-.2 � Sire_ x 12.2(f Z Number <br /> SUMPS IK/Distance to nearest: Well 3-feyl- Foundation_�' Property Line /S F 1 <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application end that the work will be done in accordance with San Joaquin County ordinances,state 4swe,and <br /> rules and regulations of the San Joaquin County <br /> Home owner or!icensed agent's signature certifies the following: "I certify that In the performance of the work for whk:h this permit h leaved,I sfsap nor <br /> employ any person in such manner as to becono subject to workman's compensation lows of California."Contractola hiring or suDconleaved,ctift signature <br /> tionconlrtioll the 4ws off Calila la. I certify that in the performance of the work for which this permit is'Sound,I shall employ persons subject to workman's companw <br /> The applicant must call for all required Inspections. Compete drawing on reverse side. <br /> �u /J ' n � YYYc"` <br /> Signed X w-ryJ G!/Y7ZY �Itb:_, <br /> �— ._ Dau: —�'Z "�'7 <br /> _ 1-11"OR D kRTME SE ONLY c7• <br /> Application Accepted by Date Are <br /> Ph or Grout Inspection by <br /> � <br /> .late Final Inspection byVDate <br /> Addit)nal Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Serviceu if <br /> Environmental Health p;rmit/Services <br /> - 445 H San Joaquin, ox 2009, Stkn, CA <br /> 93201 <br /> FEE AMOUNT DUE AMO T REMITTED REC[IVED 0Y <br /> INFO DATEPFRMR'HO. <br /> EN 13-24(Ail rix sl <br /> . EH 14.31 <br />