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r t "PLICATION I OR Yh"I T T , <br /> SAN JOAQUIH COUNTY PUBLIC HEALTH 6ERVICE8 <br /> ENVIRONMRNTAL HEALTH DIVISION <br /> P O SOX 2009 , STOCKTON , CA 95201 <br /> (209) 488-3447 <br /> EBEN11 EXPIRES 1- TEO YBQX_12ATB LjM= <br /> (Complete in Triplicate) <br /> Application is hereby reads w San Joaquin Countr for a flervit to const-6ct and/or icst1.1 the vort berein ecac^ford This <br /> aFylicatiaa is rade In Ccepllarica vitt 3sa Jmqul-1 County Ordiaaact !to 5t9 aro 1062 ati ttv RWei " AcgulatioGa or San <br /> Joe.Quir. County Nblie Health 8errlces <br /> Job addraia _./,5 �� 1/71111 -7,QE-CT,,. .- - -- - - City r !!�14 Lot S l to/Ac reege <br /> (?wr+rr s Nara L Address ??l S-A <br /> .�krL4n v 1,2irt10120 Phone <br /> P&j.46, TV -75ZCI <br /> ' renlr✓ILt3rTlr�cK�f $T 1�Z74`i�' sada ess . - - - L cense Ho&67-,0zZZA Pone 41bg5L 74 54- <br /> TYPE OF WELL/PUMP NEW WELL ❑ •WELL REP{ACEMENT Q OESTAL,CTION 0 Out of Stirvtta troll ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 'I OTHER (j A4.-D4t.orj LE 5lell �/ <br /> DISTANCE TO NEAAEST SEPTIC TANK SEWER LINES DISPOSAL. FLO PROP LINE J►� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL__ ___ PITS/SUMPS _ <br /> ' tNTEhOEO USE TYPE OF WELL PROBLEM AAEA CONSTRUCTION SPECIFICATIONS <br /> Industrial O Open Bottom 0 Monleca Dy of Will Escaval.on Du of Wall Caving <br /> L Oomest.elPr,wu 0 Gravel Pack n Tracy Typo of Casing Spectl'cations <br /> P,rDlrt 11 011ier ❑ Delta Depth of Grovt Sast Type of Grout C <br /> U <br /> G Irr +tion A Odie; Depth ❑ Eastern Surfa'ce Sear Installed by <br /> Rioa•r work Done U 'Type of Pump _ Ft P Stain Work D <br /> wom Lles(ruelion P Wel! Druriow " " 5taling }k Gerin! i DrPLL <br /> Tiller ?4surlel i Depth 2 gC,� 5. <br /> TYPE OF SEPTIC WORK NEW INSTALLATION!0 REPAIR/ADDITION M OE5TRUCTION J INo saotic system pef"mued rI plrblrc sev.yre q <br /> tivadao.e within 200 leer ) <br /> IrlelatlalrOR veil serve Aesrdance -___ Coirvhgecial____ Other <br /> Number of rev4N until Nvmber of b*drooms <br /> CM►acta of wt to a depth of 3 feet hater Labla depth <br /> SEPTIC TANK 0 TYpe/Mfg Calwity No Coevvian wirs <br /> PKG TREATMENT PLT Cl Method of Drapoasl <br /> Dlatanae to nearest Well Foundal.on � Property Line ,_ <br /> ' LEACHING LINE 0 No b Length of lines Tolal length/site <br /> FILTER 8ED n Dwxr%c•?nearot Well FovMalbn Property Ura <br /> I <br /> SEEPAGE PITS I I Depth S're Nvrnber <br /> SUMPS Ll Distar+u to r%aveii Welt Fourdat.on Property Line <br /> DISPOSAL PONDS O <br /> I t+ereby cert.Ty that I have prepared thu applicIttron and chat the wort. wdl be done in accoryince with San Joaau,n courty ordmances stats leers and <br /> rvles and rigvtat.ons of the San Joagv,n Cwnty <br /> HOT* Owner or I+C6niad igenr s sgnotvre Cert(.aa IM I'11ow no I certify that in the per1ormar+Ge Or the w01k for wt1.Lh th+a perrmt U jssuad I "D not <br /> en%PIOY any PeraOn in wch ma/+e,er as to 04como Wbiecl 10 workrr3n ► wmDeridtton laws of C11doema Ooilroclor i hiw%n or svt�-con[racling s+gnalura <br /> certrfHa N follow-ng I tartify lhil m the plr10rR4rvC6 at 04 work for wh'Ch this por^nrt,1 .lautd I 3"V1I ampIgy peraoru avb.act 10 NQrkM4n; cOrr,7ans� <br /> boll Eawe 01 cotforrda <br /> The alapticant v.Gsl (.atl brM requ fir! rntpi,IW# Co rp•e,a drewng On reverse side <br /> 'S'gr-d TaW Dart <br /> YAR DEPARTMENT USE ONLY <br /> Aptalicstion Accepted by — y _ 0114 Area <br /> �t or Orout fnape-Mon by Qat• Final Impaction by ` Dau <br /> i rllonal Comrmant/ <br /> Ppli<aa; ROLUTM LUCOPie/ to SAN JOAQUIN COUNTY PUBLIC HIALTB SERVICES — <br /> L-gVIRW)dENrAL If6Al.Tt1 DIVISIOX pPJtlfit/3E:Itv10E3 <br /> 445 is SO JOAQUIN, P 0 BOX 2008, S'iWKTOH. CA PS201 <br /> FEE <br /> blip ak4OUNT OVE AUGVNT RErt riEO C�S►t RECINE0 aY JaTE fEr1►t17 NO <br /> r?7rlafv •r•�. � - <br />