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wv <br /> ` APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> U ENV I RONM£NTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 / r <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby sade,to San Joaquin County for a permit to construct and/or Install the work herein described. This <br /> appliCatlon 1s Made 1n Compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regva&tioaa of San <br /> Joaquin t,ounty Public Health Services. <br /> , LCnvT/tom-'__ <br /> •�, Job Address T- Lot size/Acreage <br /> �- r <br /> 1 �Yi�./Ce� <br /> Owner's Nam. Ptw <br /> ConUattor P�.�ys -_Address - License No. TJ /o��_Prions' <br /> TYPE OF WELL/PUMP: NEW WELL ^ WELL LACEMiNT n DESTRUCTION 0 Out of Service Me1I <br /> } PUMP INSTALLATION O SYSTEM REPAIR C] OTHER O Monitoring well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - PROP.LINE <br /> ! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - <br /> 0 Industrial ❑Open Bottom ❑Manteca Dia.of Well Excavation Dia.of Well Calling <br /> ❑Doestic!Private C)Gravel Pack ❑ Tracy' Type of Casing_ Sp+eeificatbrla <br /> rn <br /> 1.1 Public Cl Other fl Delta Depth of Grout Seal Type of Grout <br /> l 1 I Wiga UOn - Approx. Depth i I Eastern Surface Sssl Installed by <br /> Repair Work Dora LJ Type of Pump H.P. <br /> State Work Done - <br /> s y, Sealing Material i Depth <br /> Wag Destruction ❑ Wall Diameter „ <br /> < Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION+ I REPAIR/AOOITION DESTRUCTION I t INC tepee system permitted it public sewer k. <br /> y available within 200 feet.) <br /> IrntsWtton wig aarva:-' Residence_ Commercial_ Other a l- <br /> Number of flying unity. Number of bedrooms <br /> Water I"depth � <br /> Character of aoe to a depth of 3 feet: <br /> SEPTIC TANKO Type/Mfg Capacity No.Compwtnwnta ' <br /> r PKG.TREATMENT PLT.❑. c Method of Diapoul <br /> Uistancs to nearest: Well Foundation Property Lk" <br /> AZT^ <br /> ;LEACHING LINE 10 No.8 length of linea — <br /> Total length/site <br /> FILTER BED in Distance to nearest: Well Foundation Property Lina <br /> -C :M <br /> ,SEEPAGE PITS .I I Depth Z.0Sire �r Number <br /> SUMPS LI Dlstanu to nearest: W Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that IM work will be done in accordance with San Joaquin eounry orGnant:es stab Iswa,�and <br /> rules and rtrpulaboos of the San Joaquin Count? <br /> d > Homy owner or licensed agent's signature certifies the following:"I certify that In the pedormlence of the work for which this permit is issued.1 aflae not <br /> q: m t employ any person in rich ervw as to becema laws Of to workman's compensation laof California 'Contractor's hiring of sub-Contra in tigMturf <br /> 5 ,+�{`^• eartNas the following:"I certify that in the Womnance of the work forwhich this parrt+it is issued I shag employ persons subject to workman's eompenaa• <br /> • 'ja�'3![` i; tion laws of catilornla <br /> spplkant 74 p for Inspections.Complete drawing on reverse aide... <br /> ` <br /> - tiedSig <br /> 1 l .r Title: Dale <br /> FOR DEPARTMENT USE ONLY u <br /> S q na <br /> ` �Sb �.� i Ajiplicaticn Aeeoptad by Date_� AT•, <br /> • "vim ( a <br /> out Inspection by ��4L Yy 'T Data_ nal Inapactbn by �% , a =4�• <br /> Addkion.l Comments ,-r1-.y ==21 <br /> Applicant - Return rill copies to: San Joaqula County Public Health Services <br /> Environmental Health Perstlt/Services <br /> 445 N San :osquin. P 0 Dox 2009. Stkn,�CA 93201 <br /> �]ny <br /> "i � ✓d s -{"A IFEENFO AMOVNT SUE AMOUNT mEMITTEO CAIN RECtRIEO BY j - DATE - PEIIMR•NO <br /> TIR11761111V.vxM .. <br /> M 16.E <br /> •MORA, <br /> vtv ^x •t„4't'. � �' ria.5:i:«.ie��tviicd«4;:Ynlr4i'Yi��'' r§361".;iiltlJ�i�mam+'ta'.�trsr.+r'.""°n"""'_. <br /> � ♦r- -f'4 r .. <br /> - <br />