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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 0 BOX 2009 , STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Comniere in Triplicate) <br /> Application is hereby made to Sam Joaquin County for a permit to construct and/or irst4LU the vont herein described ';ti <br /> application is made in cae:Plieacc vlth San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> Job Address C - ��^ 1 n 7 City Lot Size/Acreage'//'f <br /> Owner s Name / T Address jz _Z-_t5_ c"i 7 Phone <br /> Contractot/ ��' ' O Addresses /- License NoZx59772 e'-Phone <br /> TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT M DESTRUCTION C1 Out of Service Well C <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLO PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> y / <br /> Iwd+rsIrisi/-1GnI/l27r«. C1 Open Bottom ❑ Manteca Ora of Well Excavation Dia of Well Casing G <br /> C I Domestic/Prrvate dGraVM Pack ❑ Tracy Type of Casing- /7V� S� /t4/ <br /> - Specd+catians <br /> I I Public I l Other .Delta Depth of Grout Seal _ /,q -/z./ Type of Grout�U�/pr <br /> I I Irrigaimn _i2 Appro■ Depth I I Eastern Surface Saul Installed by .LIZ /34dmm/rE fly. _ <br /> Repair Work Oone 0 Type of Pump H P State Work Done <br /> Well Destruction ❑ Well Diameter Sealing material E Depth <br /> Depth 711ler Material i Depth <br /> T F SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted rl pld*c sower <br /> available within 200 feet I <br /> Insm"tion wro Residence_ Comrnercrsl_ Other <br /> Number of Irving units umber of bedrooms <br /> Character of sari to a depth of 3 loot er table depth <br /> SEPTIC TANK C] Type/M1g Capacity No. Compartments <br /> PKG TREATMENT PLT ❑ Method of Disposal <br /> Distance to nearest Well ation Property Line <br /> LEACHING LINE 0 No & Length of tinea �nqthls.zo.FILTER BED ❑ Distarme to t Well FoundationLine <br /> SEEPAGE PITS Depth Sue Number <br /> SUMPS LI Durance to nearest Weil Foundation Propeny Line <br /> D AL PONDS ❑ <br /> I hereby candy that I have prepared this application and that the work will be done in accordance with San Joaquin county ordwil"U es, state Iowa an- <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent a signature certifies the foitowtng 'I certify that In the Derfomtance of the work for which ilia pernet M Issued 1 shall nc <br /> employ any person in such manner as tp becorne subject to workman s compensation laws of California ' Contractors hiring at subcontraetmg signstur, <br /> cendoote the Iotlawmg 11 certify that in the performance of the work for which this permit is issued, I shall employ persons subjatt to workman s compensa <br /> tion laws of California " <br /> The applicant u II for all required Inspections Campiate arewinQ an�so side <br /> 5rgrted >� '�rte"til Itt[edd rZro iC_ w� 1 d !C) <br /> Rate• <br /> FOR DEPARTMENT USE ONLY <br /> Appkcation Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br />. Additional Comments <br /> Applicant - Return all copies to San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 M San Joaquin, P O Box 2009, Stka, CA 95201 <br /> FEE AMOUNT DUE AMOUNT AfMITTEo CK RECEIVED BY DATE PfflM17 NO <br /> INFO CASH <br /> . Ewt -24 ti OY I r a ai <br /> ,,, :3 <br /> it ta32 <br />