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I <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH VA# <br /> E"IE X4MTAL HEALTH DI ISI <br /> 445 N SAN JOAQUIN, PHONES (2 )468 S <br /> P 0 BOX 2009, STOCKTON, CA 952 FA�1 <br /> Ads <br /> 7 IT <br /> (Complete in Triplicate) <br /> Aaalcatiora 1a hereby ame,to Baa Joaquin county fpr a permit to construct ;and/or install the vork herein described. This <br /> apylicatian is made in ecelpliance with Barn Joaquin County Ordinance So. 549 and 2862 and the Rules sad Regulations or San <br /> i Joaquin County ".11c Health Services. <br /> Job Address I drl�. ity A61D4 Lot Size/Acreage <br /> OwnN's Name ddress A&XV2320Phon . +7 <br /> Contraetaf Address License No. <br /> �.�F�7�Phone <br /> TYPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Bervice Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Nonit:orlag Yell ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIGAt _ AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑Open Saltam L Manteca Dia. of Well Eucavation Dia. of WON Cooing <br /> [:) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specificalions <br /> I'll Public 171 Other 1-1 Delta Depth of Grout Seal Typo of Grou Q <br /> tf+flrrigatk�n Approx. depth I I Eastern Surf au Seal installed by <br /> Repair Work Done U Tyle of Pump H.P. State Work a" <br /> WN!Dwmetion D W/4 Diameter Sealing Material i Depth <br /> -- <br /> Depth Filler Material A Depth _ I`-- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION I ! DESTRUCTION I I Wo seplic system permitted If public anrwr is <br /> available within top meet.i <br /> Installation will serve: Residence__._ Comnerciaf_ Other <br /> Number of Nvi"units: Number of bedrooms <br /> Charactw of OCR sa a depth of a feet; Wap <br /> depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity_^ N Q' <br /> PKG, TREATMENT PLT.C) <br /> Distance to nearest: Well foundation <br /> Ptgpe <br /> LEACHING LINE Cl No, 3 Length of lines To tj <br /> ${ . <br /> FILTER BED tl Diatana to naareat; Wed Foundation_ ___ Pira � 8 h <br /> SEEPAGE PITS 1 I Depth ._ � _Si» Number -10 <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby oarGfy that}have prepared this appticalion and that the wank w!d be done in sccardance with San Joaquin county ordinances,state Jews, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed aga 's iignsturs osnifise the following:•I certify that in the poriormance of the work for which this parrnit is issued. I shall not <br /> employ any parson in such manner as to became subject to workman's compenaatian lawn of Ca of Contractor s hirin u ertira9 signature <br /> certifies the following:"I certify that in the performance of the work for Which this psrmll is issuer!,I shall employ per o wo I <br /> tion Jaws of CaNrarr".- nsa• <br /> The applicant must rid or ail required insp@.Clb*ns. Complete drmmng on reverse side. <br /> Sind Title: If"U <br /> i <br /> AOR DEPARTiMEN7'U8E Of V <br /> Appncetion Accepted by /��. <br /> Date T <br /> Pmt or Grout inspection by ate _ Final inspection A W Date <br /> Add tkwW Comments: -- 11* <br /> AppliCan - 6eturn ll copies to; Sax Joaqui�C�ory'publi ealth er�3�vfcesyj JR —7-4.0 .2-i <br /> Environmental Health Permit/9ervicea (} r <br /> 445 H Baa .loaquin, P Q Box 2909, Stkn, CA 95201 `~�fi�-d'�ra-a <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIV ED 8v �m� i <br /> K CASH DATE PERMIT' <br /> - EK1}MlrteV.mi�6 l,lV <br /> !H 11.E <br />