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APP L I CATION I'r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES p ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)488-3420 f P O BOX 2009, STOCKTON, CA 95201 �• +.ri . PERMIT EIPIRE9 I YEAR FROM DATE ISgCT a (Complete in Triplicate) Aapllcation-1.a Mtrolry arde to Ban Joaquin County for • permit to cor.•truct and/or install the vorY herein described. This .1• ' _ application 19 made In compliance vlth Isar Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulation of San Joaquin County Public Health Servlces. ,�14' f C tyC_r Lot Bifs/Acrease 1 -- ' tt Job Address �_ �� //�� \ Q ,ll�t .�A41eL41ia.._Phone �.7 t�.+•/��_ it �• Ownei a Name p f. __�iAddrosss�� _ License No. Contractor Address /Z�phone t1 � . F TYPE OF WELL, M NEW WELL 0 WELL REPLACEMENI I DESTRUCTION 0 Out of Service �/ monitorini Ihll Cl t. PUMP INSTALLATION O SYSTEM REPAIR Cl OTHER p[ rl 4 , DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _ DISPOSAL fLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 5 -- INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS i �H i --n Industrial 0 Open Bottom ❑Manteca Dia.of Well Ercavation 04.o/Woe Caakq Domestic/Privet• 0 Gravel Psclt 0 Tracy Type of Casing_ Specifications-- ("1 Dtha Depth of Grout;Sal Ty"of Grouter. x I'I Public I1 OtherA . 'Y ^4' I 1 Irrpation Approx. Depth I I Eastern SI 19`fall sU DY H.P. State Work D • *t? Repair Work Dons Type of Pump r� �a y. h 8aalitt6 Material D,ryth ,'� 4 Well �. -Destruction O Well Diameetteer .d.Z71t/le►� Depth TYA OF SEPTIC WORD(: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I INo sept,c"am permitted if public eeWt/10 �! available r,ithin 200 feet.) �t Installation v,11 serve: Residents_ Commarcial-_ Other d/� 1 � {1�/ N Number of living units:_ Number of bedrooms 19La ��'`'/�'r.,•rdz Character of sto a depth of 3 feet: Water table Apth ole � o SEPTIC TANK 0 Type/Mfg _ Catecity No.CompaMwrit PKG.TREATMENT PLT,0 Method of 13*0481 i)gT Distance to nearest: Well Foundation — Property Lira i -e LEACHING LINE O No.1'.Length of Imes Total length/sitePAYMENT FILTER 8ED 0 Distance to nearest: Well Foundation Property� � 6 tI 6 > r { SEEPAGE PITS I 1 Depth Site Number 19,92 .'' BUMPS Ll Dist..nce to newest: Wall Foundation_ Propg �CjL)NTY I Ir.HE�LI H SERVICES DISPOSAL PONDS 0 ,+ -.A1.+7 e'er} �•`: '•"` I Hereby cenify that!have pspared this application and that the work will be done in accordance w �B'At(?I •sr to bwa•Ind rules and requletWns of She San Joaquin county „ Home owner or licartsad agent's signature certifies the following:"I certify that in the performance o}the work for whkh this Deere M issEMd,I own mOE .l employ any person in such manner as to become wlh.vct to workman's companuTion 4,vva of California.-Contractor's hirktp a wrtseontrsetMp siprletun certifha the fosowinp:"I certify that in the perlormence of the work for which this permit is issued,1 shall employ persona subset to waknsan's oompMsa- - 6 tion laws of California." u The applkant must call for squired inspections. Complete drawing on reverse side. r S' 1*.'x4p,�, s�.�✓ Titre ' Date: Sig A= FOR DEPARTMENT USE ONLY 1; S Apalicatlot Accepted by Data ser Pit or Grout Inspection by Date Final Inspedtkan by Dow, Additional Commww: Applicant - Return all copies to: San Joaquin County Public Health Services _ Sovironmental Health Perelt/Becvicee `✓ {, 445 N Sen Joaquin" P O Box 7009, Stkn, CA 95901 FEE f 4 INFO AMOUNT DUE AMOUNT REMITTED CAS N _RECItVID BY DATE ►IRMiT'N0, r a;' ,: Em 1324IRM.11.81/'� rl7 v �Lj, e �� 7 127 5 Z.- .. Err 14-20 .,. ,. ,:.r—p-^-. Y'wwriws++m�t#1rat,4.qL.: �.yC�;•rr'AY1a,'a±,y;,...� .a-«; M a:�,Y,..yl,,' 'r ,t'rr:�?„.,ar.��ad�.'vf 4wS+tt•r .e�� i 1 r r