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' APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH D I v I S i oN <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCXTON, CA 95201 <br /> 2ERMIT EXPIRESPROW D E II <br /> (Complete In Triplicate) <br /> Application is hereby made to San wo*quiz County for a permit to const.-.1c: and/or instal' the vori here-'a described. This <br /> licstion is made in caetpllaace with San Joaquin County Ordinance So. 5.9 and 1862 and the Rules and Regu.Lations of Sea <br /> IZuin County Public Realth Ser^►icee. <br /> Address <br /> Jots <br /> 3'783 �re��-, rrlo.a �t.i�r c Cup r�Lv Lot Size/Acreage <br /> Z O.Oo G a..� r .e, <br /> �ner t Name <br /> Address S ,.ie. 40� S•. . rZt.nvn LAjv5"a Phone Z77- ,z it <br /> all AVCA .- / <br /> Dr 0 1 kw rnc- Address fAc--- 1-2 P-..ia e-A '5yd Z; License <br /> �l�o <br /> 37'�I J 2 Fisons 'a! �Z�- Z90 <br /> QF WELLlPUMP NEW WELL WELL REPLACEMENT C! DESTRUCTION ❑ Out of Service Yell <br /> Pi: ❑ <br /> monitoring �d <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER 13monitoringJ't <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES f D tT- DISPOSAL FIX PROP LINE L.0-4 <br /> FOUNOATION AGRICULTURE WELL OTHER WELL 20 4- PITSISUMPS <br /> INTENOED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> � sn�t+� <br /> C} Industrial ❑ Open BOaom Cl Manteca Eta of Wail Excavation Ota of WeA CAS-19 <br /> sly#- <br /> Domestic/Private 39 Gravel P" �9Tracy Type of Caseng_Szl-'�A- �a AVL Spectfieaaorul 1-00, <br /> T of Grout CCA:t�^` `z <br /> Pteblic f'1 Ottani Cl Delta Depth of Grout Seal pigs <br /> II I Irrigation <br /> 'Z6�Appros Depth 11 Eastern Surface Ssa1 installed by <br /> paw Work Done U Type of Punep H P State Work Done Z <br /> all Destruction 0 WON Duimeter Sealing flaurial i i=i <br /> Depth Tiller flatsarial A DWPTb �\ <br /> TYP£ OF SEPTIC WORK NEW INSTALLATION I I REPAIRlAOO(TION I t DESTRUCTION I 1 a�va septicable SYSn m1 N t}ed It public sewn is e7 <br /> �tausaon wit serve Residence Other _.. <br /> Number of Wing units. Number of bedrooms <br /> Cltaractrr of and m a depot of 3 fact: <br /> water table depth v•. <br /> �EPTIC TANK ❑ Type/Mfg Capacity No Coniipartmarits <br /> KG TREATMENT PLT ❑ Method of Disposal <br /> DKiar>ce to riaarew Well Foundation Property Lina <br /> EACHING UNE 0 No a Length of lines Total length/sue <br /> FILTER BED ❑ Distance to newsm Welt Foundation Property Luse <br /> EEPAGE PITS I I Depth Sirs Number <br /> UIMPS Ll Distance ton ONO Weil Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> ILhereby twisty that I hew prepared ,tus appn licatioand that rite work will be done tit accordance with San Joaquin countlr ordenanees, state laws. and <br /> les and regutattons of the San Joap Lim Coaety <br /> F4orrr owner or hCensed agent s sigr+stura certifies the fo0owmq "1 conrly that In rtio perfomsence of rhe worst for which this pwmt a issued.I shO not <br /> employ any person in such rnsnner as to become subject to workman s componsatton larva of Caiifornta Contractors htnnq or sub-contrsctrng sig <br /> nature <br /> tires the fobwr+q "I txirofY that rs the Perlorrnance of the work for which this perms is issued. 1 shall employ persons subject to workmen s con"nsa- <br /> laws of Caldomia." <br /> The applicant must cad for aM rpured Complete drawing onraveraa side.— rte. �+�C.�. 11111610'f <br /> If <br /> � x C yam, �, _ rltle Ser+w� d s Eat.: N z <br /> IS 0 FOR DEPARTMENT USE: ONLY y <br /> Appltaation Accepted by Date Area " <br /> Pit or Grout Inspection by r, Data FtrW Inspection by nate��- <br /> rtlonal Comrt+ents !1 }el S 3 &*-S� ��+-+�'� IA- <br /> Applicant - Return all copies to San Joaquin County Public Health Services <br /> Havironmental Health Permit/Services <br /> 445 N San .Tosquin, P O Box 2009, Stka, CA 95241 ` VI <br /> F£g AmOuNT DUE AMOUNT AEMiTTED CASH RECErveo by ow7E ►EPitTt Id8 � <br /> INFO <br /> 1-2.IrtlV 9 J06 4a5 N <br /> po ria' <br />