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t <br /> r <br /> 4 <br /> { <br /> APPLICATION FOR PS-_"-• <br /> h SAN JOAQUIN COUNT`.' PUBLIC HEALTH SERVICES 1 <br /> FNVIRONYSNTAL ILSALTH DIVISION r <br /> 3 P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 4 <br /> "WIT RXP;RRS 1 YEAR FR69 DATE ISSUED <br /> (Complete 117 Triplicate) <br /> AnUcstion a hereby ttsade.to ffsa Joe4ulo County for a perait to construct and/or 'nstsl! the work herNa described. This <br /> syyllcatioe is Mads in coyliaace vith flan Joaquin County Ordinance No. $49 •red 1662 and the Rules and AeaulAtions of Ban <br /> JasQa Cady I►trblle NeL ""Ices.ul <br /> :u0 Address �_�.ZC_ E 1•f C�1'�c_w !C Cry-�iln1��-_ Lot SiNiAcrease �j2 XyJ <br /> Owrtsfa Nwna _ )A 11I 1 .�L�P AOd,.s. 1/?�_�__F= �'1l 06-121.�1S;S_ Phone S Uo <br /> • Cantfaclor pr -YV4—_ Addrett _L,CfAse No. Phone <br /> OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT [I DESTRUCTION R Out of Service Well <br /> ft,MF .I`STALLATU' ;•r SYSTEM REPAIR 0 OTHER 0 Nonitoring Well Q i <br /> DISTANCE TO NEARELT: SEPTIC TANK SEWER LINES DISPOSAL FLD. '- <br /> FOVfrOATTON AGRICULTURE WELL OTHER WELL PITS/SUM='.-, <br /> INTENDED USE TYPE OF WELL PRCBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Nsdwwmel O OW Bottom 0 Manteca 0•4.of WON Eatavalon Du.of Wall Casing <br /> O Domaetic/Mvats 0 Gravel PWA 0 Tracy - Type of Casrng Specd.cattons \ <br /> D pullik n otfw 0 Delta Depth of Grout Seal _ Type of Grout <br /> — <br /> a hmetton ._Approx.Depth C Eastern Surfite Seta Installed by i <br /> Aapw Wort Done 0 Type of Pump <br /> H.P. Bute Work Done_ <br /> WillOaatruabon O WN Dwrieea <br /> Sealing Maurlal A Dr;t►. C ) <br /> Depth FlUer aLtarial i Depth <br /> TYPE EP WORK: NEW INSTALLATION JO REPAIR/ADDIT104.0 OLSTAUCTIONjr INo sePnc system permitted I pubrt sewers t <br /> sva.sLAO wrllun 200 feel.) <br /> bmumum wo sews, Asodwtos_ Cornniercial_ Other <br /> Number of ivW4 writs: Numt*r of bedrooms i <br /> Chwwtw of sed W a d.pat of 3 test: Water table depth <br /> fEPf1C TAAIK O Type/IAtp Capacity NO.Contpsnmanu' ; <br /> rrICO TREAT6AENT PLT.O Method of Drpossl r <br /> 1 i DWAr4o to nearest: WON Foundation Property Lme <br /> 1EACH040 LINE 0 No.S length of tines Total length/sire <br /> S r <br /> F!LTEA BED 0 Dntsncs to nearest: edea Foundation Property Line <br /> w <br /> A <br /> 'AMA"PITS f I Depth Sire Number <br /> LI Disteme to newest: WOO Foun dal on Property Line ; <br /> DISPOSAL PONDS 0 <br /> ''t hereby ci rWy chit 1 have pmpwW true&Ppikabor.erro that the work w-Jt be dons in accordarue with San Joaquin county ordinances•state laws, and S <br /> rt4i;and reprWiorle of this San Joaouii County ;I <br /> -►W ho owrtar or Soonaed bow's ripnahare coni(."its follo+v.ng:"I certify that in the performance of thew-:for which this parmii is issued.1 shall not Y _ <br /> ti•asnploy avow Person in ruts rttww+sr as to become wjbwct to workman's comwnasuon laws of CsZlorma.• Contractor's h«ing or wtrcontrsctirp signature <br /> .aMt✓�ai par foaov imp:'9 ax0y tel[N the pwfomtence of the work for which this permit is issued.1:hall employ persona subrect to workmui s conpenss- <br /> ,ifon Mere of CaWamle«. { <br /> The�pplkant t�X for so ad insp�ctions.Complete drswing on revwse side. t <br /> 'Q_(�` Title: _l_"t� Data: `2 0 <br /> SipnsO USE ONLY AQplkadon Aotsp»d by �a M�DEPARTMENT <br /> '� � Dau — O At" <br /> p <br /> rq or 4WA Mspection W Date Frost Inspection D Ora / o ppp <br /> Applloant- Bstvra fall COPles tot BAN JOAQUIN COUNTY PUBLIC HULTH SnVICES <br /> 3XVIAOKILEKTAL BILALTB DIVI3I0M PEXXIT/SERVICES <br /> 445 N SAN JOAQUIN. P O BOX 2009, 3rXXTON. CA 93201 <br /> CK 8 <br /> WFC rNOUNT OVE AMOUNT AEhAITTEO GASH AECErd[D ay OAT[ <br /> . <br /> If"-.4-a <br />