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93 <br /> APPF,ICATION FOR P ITcc���""-��-}}--"` <br /> SAN JOAQUIN COUNTY PUBLIC TH� {V3 / <br /> ENVIRONMENTAL HEALTH D I I� <br /> 445 N SAN JOAQUIN, PHONE (2 - <br /> P O BOX 2009, STOCKTON, f3 }l t 0i-RI <br /> (Complete in Triplica 9MKP/f <br /> Application is hereby cads to Baa Joaquin County for a permit to construct and/or install the vosk herein described. This <br /> pp <br /> Ilioa <br /> tian la Iseult 14 caspllaace vItb San Joaquin County Ordinance No. 509 and 16b2 sad the Rules and ReSulatlons of San <br /> Joaquin County Public Health Services. <br /> Job Address City Loaf Lot Size/Acreage <br /> Owner's Nome6 e 1 � Address a Phone <br /> AA 10Lt <br /> Contractor ddress ' License No. Phone 404t <br /> TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT 1 DESTRUCTION O Out of Service Yell <br /> PUMP INSTALLATION Q SYSTEM REPAIR L7( 6THER Q Monitoring Well a <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WF_LL===t=� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFiCAnoNS <br /> L1 industrial 0 Open Bottom G Manteca Dia. of Wall Excavation Clis. of Well Casing <br /> �) Domestic/Private 0 Gravel Pack O Tracy Type of Casing- <br /> V1 Pubik 1-1 Olher n Ostm Depth of Grout Seal ype of of <br /> I I Irrigation _Approx. Depitt,DeptI I Eastern. Surface Seat Instahkrd by <br /> Repair Work Done U Type of Purnp H.P. Stow Work Done <br /> Wa8 Destruction D Wall Diameter Sealing terial 4 Depth <br /> Depth !�� filler material t Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADOITION I I DESTRUCTION I I IN*sepric system permitted it public sewer is <br /> available within 2W feel.) <br /> Installation wifl serve: Residence._.., Commercial_ Other. - <br /> Nurnber of living units Number of bedrooms <br /> Character of aw to•depth of 3 toot. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments <br /> PKG. TREATMENT PLT.Cl Method of Disposal <br /> Distance to neanet. Wel_ Foyndation_ Property Lira N <br /> LEACHING UNE O No.• Length of knos ---- , Total Isngth/size <br /> FILTER BED Q Distance to nearest: Well Foundation _ Property Lae <br /> SEEPAGE PITS I 1 Depth Sits Numbs <br /> SUMPS _ Ll Distance w nearim: Web Foundation Property Lire --- _ <br /> DISPOSAL PONDS 0 <br /> 1 hereby coyigy that.1 have prepared this application and that the work yvilf be done in accordance with Son Joaquin county ordinances, state lows, arld Api, <br /> ruins and regulations of the San Josquisr County <br /> Howe owner or licensed agent's signature certifies the following: "I eanify that in the performance of the work fix which this pernVI is issued, I shah not <br /> stnploy arw per such martrtsr ss to become subject to workmen's compensation taws of California."Contrsctoi s hiring or sub•con&actinp si"ture <br /> certifies :"f certify ttwt in the pedonn rice of the work for which this perm*is Asuod,t shelf employ parsons subject to workman"s correperiss- <br /> tion laws <br /> The call for apt mawctio . Complete drawing on r <br /> ` OS�►ed �'' T*b: Data: _ - '� <br /> FOR DEPARTMEN SE ONLY <br /> Ap~b*n Accaptad by -��lt T l�•l .s Date Arw` / <br /> Ph or Grout Impaction by Date Final Inspection by Oats z 3 <br /> Additional Comments: <br /> APDiicant - Return all copies to: San Joaquin County public Health Services <br /> 8nviroosental Health Berait/Services <br /> `.� 445 N San Joaouin. P O nn: 20m, Rtkn, GI A nI <br /> . V <br /> AMOUNT DUE MOUNT REMITTED RECEIVED hly DjPfftwil "0j.SF <br /> O CASH <br /> trk t3- 1aEV.biK►r Q(} <br /> 641baa <br />