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' APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br />' ac��r T T R7CP T ARS 1 YEAR FROM DATE ISSUED <br /> DED <br /> (Complete in Triplicate) <br /> Application is hereby made to Ban Joaquin County for a peratit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin county Ordinance No. 5119 and 1662 and the Rules and Regulations of San <br />' Joaquin County Public Bealth Services. rr/� O� <br /> A Sir jr, - - City S4 `"` i- Lot Size/Acreage , <br /> Job Address <br /> spa' S S -H2lhf%Address �{ _ t. —r ' Phone 5 ZZ 3�g <br /> Owner s Name u j� � L��_ <br />' <br /> pit I i�h Address p'pow, � License <br /> Contractor No one l nRg <br /> WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service Well <br /> TYPE OF WELL/PUMP- NEW WELL <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well A <br /> DISTANCE TO NEAREST SEPTIC TANK �T. SEWER LINES % • DISPOSAL FLD PROP LINE r�P <br /> FOUNDATION kht.AGRICULTURE WELL OTHER WELL ' A` PITS/SUMPS _ <br /> "p ffir• OC,�•RS� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> _ pis of Well Casing <br /> C7 Industrial O Open Bottom ❑ Manteca Dia of Well Excavation G Specifications' Cl Domestic/Private Cl Gravel Peck ❑ Tracy Type of Casing l3rS _ <br /> _ Type o Grout \ <br /> I i Public Cl Other fl pelta Depth of Grout Seal Drub ' - Sy <br /> I I trngatxon —Approx Depth1 I Eastern Surface Soul Installed by <br /> �L?.--- H P State Work_Pone _, <br /> ' Repair Work Done L7 Type of Pump Sealing Material i Orpth ' A3��3-, aC,5 TrvnfL <br /> Well Destruction O Well Diameter — <br /> Depth 5 Aller Material t Depth _ St' 3 3 X25 "Y <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I' five <br /> ve sblei cystithin m permitted <br /> m tted it public seww is <br /> PInstallation will serve Residence- Comrnercial- Other <br /> Number of Rving units Number of bedrooms <br /> Water tabic depth <br /> Character of Sao to a depth o/3 feet <br /> ' Capacity No Compartments <br /> SEPTIC TANK O Type/Mfg <br /> Method of Disposal <br /> PKG TREATMENT PLT ❑ <br /> Distance to nearest Well Foundation Properly Line <br /> LEACHING LINE 0 No b Length of Imes Total length/size <br /> FILTER BED ❑ Distance to nearest. Weil Foundation Property Line <br /> SEEPAGE PITS It Depth Sire Number <br /> SUMPS Ll Distance to nearest' Wap Foundation Property Line <br /> ' DISPOSAL PONDS o <br /> I hereby certify that I have prepared this applicauon and that the work will be done in accordance with San Joaquin county ordrnancas, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature eertir'xss rile folisowing "I certify that in the performance of the work for which this permit o issued, 1 chap not <br /> employ any person in such manner as to become subject to workman's compensation laws of California Contractor a hiring or wb-contractrng ngnatuts <br /> ' cartrfies the folowwq "I certify that in the performance of the work for which this permit Is usuad.I shall employ persons subject to workman a compensa- <br /> tion Laws of Cslifomis " <br /> The applicant st call for an required inspections Complete drawing on reverse side / <br /> ' Signed Title AI`gtise�- C o�o��� _ Date �+ Z <br /> FOR DEPARTMENT USE ONLY �1 <br /> Application Accepted by Date t�`¢' Area ��O <br /> Pit or Grout Inspec0on by Date Final Inspection by Date <br /> Additional Comments <br /> Applicant - Return all copies to San Joaquin County Public Health Services <br /> Environmental Realth Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stka. CA 95201 <br /> CKE' FEE AMOUNT DUE AMOUNT REMITTED CASH Rt'.CElVED lay DATE PERMIT NO <br /> INFO --,t6 <br /> � • '� Page 1 <br /> . FirM24utty C1L <br /> Ent 14 a - <br />