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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r'NVIRONHENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009 , STOCKTON, CA 95201 <br /> PERMIT RgrPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) ' <br /> Application is hereby made to San Joaquin County for a permit to construct andJor install the wort[ herein described T` <br /> application is made is compliance vith San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of Sa <br /> Joaquin County Public Health Services <br /> Job Address <br /> City %t� Lot Size/Acreage L <br /> 1/i�C.� F dd,.,, /S <br /> Owner• Marna z Cye�fr,i�n �{i�Addre N <br /> � ss ,�L,�'-7 N �C•'YC11�nq S-�. �C. A <br /> r Sizx-tvr. ,Lc. '-{S2,c-,7 <br /> Contractor l' L?C�LC ddress ZyWLicense No - L'mGPhone - -7-, <br /> TYPE OF WELL/PUMP NEW WELLr-e- WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRhr ,pTHER ❑ Konitaring Well <br /> �� <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES-<5Q�frr*ftj-33 ell SAL F O _1 PROP LINE <br /> FOUNDATION AGRICULTURE WELL ^ OTHER WELL PITS/SUMPS <br /> iNTENOED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r*+^ **I+117civ.ttr� ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dsa of Well Casing z'10_ <br /> (1 DomesucrPrivate CI'Gravel Pack' Q Tr y Type of Casing_ ' S G Speclficatlona <br /> I I Public i I Other alta Depth al Grout Seal `� / r Type of Grout _ C-c <br /> 1rr10+awn <br /> 1041)Prait Depth I I Eastern Surface Saul Installed by A4 <br /> Repair Work Done L] Type of Pump H P State Work Done <br /> Well Destruction ❑ Well Otameter Sealing Material h Depth <br /> Depth Thier Material i Depth <br /> TYPE OF SEP WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No sapitc system pagwatted d public saww a <br /> available within 200"Leet 1 <br /> lnalallstson wall se Residence Commercutl, Other <br /> Number of living units Number of bedrooms <br /> Character of sod to a depth a set Water tabkl depth <br /> SEPTIC TANK ❑ Type/ Capacity No Compartrrlenn <br /> PKG TREATMENT PLT ❑ Method of OlsposN- <br /> Ohunee to nearest Well <br /> F anion Property Line <br /> 71 <br /> LEACHING LINE Cl No & Length of Imes Total length/size <br /> FILTER BED Cl Distance to nearest eH tion Property Line <br /> SEEPAGE PITS I I Depth Sue I tuber <br /> SUMPS LI once to nearest Wap Foundation,�,_, Line <br /> DISPOSAL PONDS <br /> hereby Canity that I have prepared this application and that the work will be done on accordance with San Joaquin county ordinances, state laws, a+ <br /> rules and repulatwns of the Son Joaquin County <br /> Home owner or licensed agam's signature candies the 11e1110vM9 1 Certify that in the performance of the work for which this permit Is aukod I shall n, <br /> *-play env parson In such manner as to become subtect to workmen a compensation law*of Caldornta Contractor's hiring or sub-contracting signstu <br /> candles the following 'I candy that in this peftO money of the worst for which this peanut is Issued, 1 shall ernPkW persons subpset to workman a compens, <br /> non laws of California " <br /> The applicant must up for all rputfed inspections Complete drowsnq reverse side �{ <br /> Signed X °"' <br /> Dat. 1/ 4 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Ana <br /> Pit or Grout Inspecuon by Date Final Inspection by Date <br />. Additional Comments <br /> APPiicant - Return all copies to San Joaqulo County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Bos 2009, Stka, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK it <br /> INFO CASH RECEIVED BY DATE PERMIT NO <br /> EM 13-=4 IIIEV It"53 <br /> EM 14-31 <br />