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APPLICATION . <br /> SAN _ ,AQUIN COUNTY PUBLIC HEALTH _ CES <br /> ENVIRONMENTAL. HEALTH DIVIS <br /> 445 N SAN JOAQUIN , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicaze) <br /> Application Is hereby made to San Joaquin County for a pertrit to con:�.y*4 and/or instal-I the work herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance N:.+r, ;-;49 and 1662 and the Rules and Regulations o: San <br /> Joaquin County Public Health Services. <br /> Job Address c l 'G r"'"'�yR City r�7C Lot 5!ze/Acreage <br /> i <br /> Owners Name / J/ Address " r'rd/"/LG� r/> fIG Ivo Phone ��/-�j / <br /> tM4 � �4, ,cee Ne62,7t- 57 Phone (9 )W,1-67gJZ <br /> Contrcor Address 3� � <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT 7 DESTRUCTION -7 Out o. Service well G <br /> PUMP INSTALLATION_C SYSTEM REPAIR C OTHER Monitoring WW ll <br /> DISTANCE TO NEAREST: SEPTIC TANK > 50 r SEWER LINES '�' 5D - DISPOSAL FLD.N� PROP. LINE <br /> FOUNDATION --&A- AGRICULTURE WELL ` r)THER WELL---I[G! PITS/SUMPS &zI °�In <br /> all f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (\�1 <br /> G Industrial ❑ Open Bottom ;)Manteca ^ia. of Well Excavation Dia. of Well Casing <br /> d <br /> 7'. Domestic/Private C Gravel Pack. J.�7 Tracy ape of Casing_ Specifications <br /> I'' Public (7 Other 177 Delta Depth of Grout Seal 0-tv /U Type of Grout <br /> eme,� <br /> 1 ! Irrigation _Approx. Depth I I Eastern Surface Soul Installed by dr, l-r ✓ ✓�P M <br /> Repair Work Done U Type of Pump H.P. me Work Done _ 11 <br /> Well Destruction C Well Diameter Seal_ 1-�terial i Depth _ <br /> Depth Fil1�- 'Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION ; 1 DESTRUCTION 11No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial_ 1ther <br /> Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg. Capac0. No. Compartments <br /> i <br /> PKG. TREATMENT PLT. C Method of P4,posal. <br /> Distance to nearest: Well Foundation rroperty Line <br /> -za Rz� <br /> LEACHING LINE C No. b Length of lines Total length/size ^ <br /> FILTER BED C Distance to nearest: Well Foundation Property Line <br /> CN T Y <br /> SEEPAGE PITS i l Depth �6ize _� Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C <br /> I nereby certify that I have prepared this application and that the work will be cone in ar ce with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such mann as to becgme subject to workman's compensation laws of California.- Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify n the 'rlormance of the work for which this permit is issued, I sh-4L+moloy persons subject to workman's compensa- <br /> tion laws of Cali r a <br /> The app a c 11 r II r inspections. Complete drawing on reverse side. <br /> '—'�— 1992 <br /> Signe Title: Pic La, ,. anager Date: July 1, <br /> k Doc m, E.G. FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �` r Area <br /> Pit or Grout Inspection by Date �� Z Final Inappction by Date <br /> — <br /> Additional Comments: <br /> Applitant - neturn aYl copies to: oa' +'taquin County Public health Services Q <br /> dnviroomental Health Permit/Services on <br /> J <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA (co, <br /> a, <br /> FEE AMOUNT DUE AMOUNT REMITTEO CK CASH RECEIVED BY DATE PERMIT`NO. <br /> INFO ]J� / <br /> 7n4f <br /> EiJ:�iAEV166 . X �� I Z <br /> r, !v✓l/F�/ <br /> EHu. a v(� <br />