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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLICTl VICES <br /> ENVIBONJIENTAL HEALTH DI ISIO <br /> 445 N SAN JOAQUIN, PHONE (2 A,4P}13420 <br /> P 0 BOX 2009, STOCKTON, 95/ # <br /> +2{551 1 <br /> PERMIT I 1 YEAR FROM ATE <br /> (Complete in Triplic t Clef—. <br /> Application is hereby lldG t0 Sm Joaquin County for a permit to construct and/or Install the work ere T=esczTSM_--7ni, <br /> aypllostlon is s de in C=Wliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and RegulAtions of San <br /> Joaquin County Public Healthvices. <br /> Job Address CitY(/�n Wt Size/Acreage <br /> Domer'e Name ) Address L Phone 6&V <br /> Conhactor �tnLC tlmess '� �-' G�-tet License No. `72_20 V-S Phone �7 <br /> TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT r DESTRUCTION U. Out or Service Well ❑ <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE __ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial ❑ Open Bolton ❑ Manteca Die. of Well Excavation Ola. of Well Casing <br /> C' Domestic/Private Cl Grave! Pack C Tracy Type of Canine- Specifications <br /> i"I Public fa Other fl Dehio Depth of Grout Seal Type of Grout <br /> 1 i Irrigation __ Approx. Depth I I Eastern Surface Seal Instilled by <br /> Repsw Work Done L: Type of Pump f1.P. State Work Done_ <br /> Well Destruction C Welt Diameter Sealing Material E Depth <br /> Depth Filler Material a Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION i I REPAfR/ADDITION DESTRUCTION I i INc septic system permitted it public sewer is <br /> available within 200 teat_I <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of kving units: _ Number of becrooms <br /> Charecter Of soil to a depth of 3 fast Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. r fai depth <br /> PKG. TREATMENT PLT. p issai <br /> Method of Disposal <br /> Distance to nearest. Well Foundation _ Property Line <br /> LEACHING LINE ❑ Ni g Length of lines <br /> �T�ota�l 210--it <br /> FILTER BED O Distance ro merest: Well or,ncabon— 10--c_. Property Una <br /> SEEPAGE PITS 11 Depth Sire Numpar <br /> SUMPS LI Disunce to neuesc Weil�ncation Property Line <br /> DISPOSAL PONDS ❑ <br /> i hereby unity that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, aro <br /> false and regulations of the San Joei County <br /> Home owner or licensed agent's signature canifys the following: "I canify that in Ins Performance of the won for which this permn is issued, I shell not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certify$the following: "I unify that in tM performance of the work for which this permit is issued, I shall employ Persons subject to workman's compeni <br /> lion laws o1 Cal 101114 " <br /> The applicant must call for Rel required inspections. Complete drawing on reverse side. <br /> Signed K._"rte Q <br /> -�rne: /V ,>. - - .— Date: _�:-i- --`�`— <br /> FOR DEPA R7 N7 USE ONLY <br /> �T <br /> Application Accepted by _ Date t'y/T Ares <br /> n w Grout Inspection by /� �du� Date (��Q'�f Irol Inspection by ��- J��Z�// Data <br /> ( <br /> Additional Comments _ <br /> Applicant - Return all copies to: San Joaquin County Public Ifealth 7r SSirvices n �r���`11 Bnvironmen tal Health Permit/Services b <br /> 1\ 445 N San Joaquin, P 0 Sox 2009, SCA 95201 <br /> PEE AMOUNT DUE AMOUNT REMITTED <br /> INFO r�'] 1 ( ] K RECEIVED BY DATE PERIiii. <br /> EN Call IaEV.rr•u �K '+ -Vv L1`` <br /> 1 -,fit 5`Y 9 a�by <br />