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f SAN 1.0QUIN COUNTY PUBLIC HEALTH 6ohVICES <br /> ENVIHONKIXTAL HEALTE DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)458-3420 <br /> P 0 HOZ 2009, STOCKTON, CA 95501 <br /> PSB![IT ffiPIEBB 1 YEAB PBOIE DATE ISSUED <br /> (Complete in Triplicate) <br /> Applieatica Is last by and* to San Joaquin County rar A perait to construct and/or inetall the work herein described. This <br /> application.I$ ads in oaalplleece with Bao Joaquin County Ordinance Bo. 549 and 1862 and the Rules and ReNletims Of San <br /> Joaquin County Public Sealth Services. <br /> Job Address fAA+ I � City ' Got Size/Acreme <br /> Ownses Nn^w -NBwILZ a^L. Address � fA3f I I'S SkM..+— phone <br /> Contractor tea- a 1'^d Address— JD fMa4, •6h License No.�„L '�Phone <br /> TYPE OF WELUPUMP: NEW WELL O WELL REPLACEMENT Ll DESTRUCTION It Out of Service <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Wall O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n IMuariat O Open Bogan O Manteca Dia. of WOE Excavation Die. of WON CeeMq <br /> n oomookip*4@to O Gravel Peek 0 Tracy Type of Coming SpwiScavans <br /> 11 Lhrblk In other n Do" Depth of Grout Seal Typs of Grout <br /> I I hriq~ —Approx. Depth I I Easton Surface Seth ImtMMd by <br /> Rspsk Wok Done U Type of Pune __� M.P. Steer Work s <br /> WM Destruction s WIN "Oil" Natorial A Depth O <br /> _ pspth 13 1 pills IYters" a Vega <br /> TYPE OF : NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 I="h" it public sewer is <br /> awin <br /> Irteteaeean w91 serge: Residence_ CaaneeUl_ Other A,a <br /> Nu Who of Ifybg writ:_ Nonko of h.aaarrs '1 <br /> Chraci r at call to a depth of 7 test: Suter table depth <br /> SEPTIC TANK O Type/Mf9 Cepedry No. Campabwnu <br /> PKG. TREATMENT PLT.O Method of DhPood <br /> r� Distance to neaat: Well Fa mid ion - Pmpw*Lim <br /> LEACHING LBM O No.A Length of Ems Total Wgth/des <br /> " FILTER BED `P1^ A O Diane"a newest: WaitFoundationion Propoty Lim <br /> SEEPAGE MTS+ I I Depen Sine Numbo <br /> SUMPS PO4A LI Orta ce to mesa: Wall Foundation ft*MW Lim <br /> OWPOW O <br /> 140 WV senMy the I heye_preperdio thapplatbn and that ton work with be done In accordance with Sen Joaquin eourdy ordimnax, autoHwa,and <br /> Nes past wpUWrns of the"San jamew Daetd <br /> Now oyma or licensed agates siSnakwo c 'Ree the folmin f:"I arWV Lha In dw Pwf*"nmes Of the work far uelah thU pwn*is iawMe,1 aM2 not <br /> sine"any pow N A"mase es to boom solnet to wor~s oampo s~Ism of California."Contractees hiring or PA•.weestirg eiBneaxe <br /> . 'a eU 1n tawLna•9 coaly the in Ute perfonseem of the work for which this permit is Uered•I NUM or play persons subject to workm nt'►ocent;~ <br /> tion Was of CaMatda.•• <br /> The ppLkaM myEaE for aE reLukW,MApecN•�E m mmse side. <br /> Signed M (/ ///• TWA: —.4. Sc�C3 ow: / Q <br /> fIOR DEPARTMENT USE ONLY � <br /> Application Accepted M Case / •7t�j_ Ares t l, A•o, <br /> PR or arm' by OM f Inspection by orae <br /> AsawnsfCammorm 694ZML may(p/�a ,@Aa&AMWAjo <br /> Applicant - Return all opies to: Baa Joaquin County pablio Eealt4 rvicee V <br /> Environmental Health pereit/8ervlcee <br /> 445 E Ban Joequis, P O Box 9009, Stkn, CA 95201 (�` <br /> 11 0 KSI <br /> AiMMiT ON AMOUNT RaeTTEO CA N RECOWD 9V DATE QPERe9T'NO. �j�+ <br /> I OW.t., brbpb Q� ?433 �i9E% �R✓ / Z Pot6� h` <br />