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<br /> APM I CATION
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL REALTH DIVISION
<br /> 445 N SAN JOAQUIN, PHONE (209)468-:3420
<br /> P O BOX 2009, STOCKTON, CA 95201
<br /> RERMIT EXPIRE5-1 YEAR FR D _
<br /> (Complete in Triplicate)
<br /> Application is hereby toads to San Joaquin County Cor a perzlt to construct and/nr inetAll the work herein described. This ,
<br /> apTlicetloa to made in eoalplianee with aaa Joaquin County Ordinance No. 549 and 1e62 and the i°ules a.nd Regulations or.San '
<br /> Joaquin ^,ow+ty public Health Services. -
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<br /> Job Address es -,_,.. City Z40fs�G' Lot sig .'acreage .
<br /> -
<br /> Owner's Name
<br /> Address -/ - Phone
<br /> Conuacfor ,,,i Address License No. Phone
<br /> TYPE QF WELLrPUMP, NEW WELL Q "ELL REPLACEMENT P DESTRUCTION (1 Out or Service Veli Cl
<br />_ PuMP INSTALLATION C SYSTEM REPAIR 0 OTHER i_; Fnitoring Well G� ,
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _- DISPOSAL FLO.___.__,• PROP. LINE
<br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIT SISUMPS
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<br /> INTENDED USE TYPE OF WFLL • PROBLEM AREA CONSTRUCTION KPECIFICATIONS
<br /> .l In sthet C)Open Bottom ❑Manteca Me (5f Well Excavation G Dia. of Well Casing ,
<br /> pornasiiclprnvate 0 Gravel Park 11 Tracy Type M Casing-___ Speu'icat ons �1 .
<br /> 1'1 Public I'1 Other I'l Oefta rJepth of Cr-oul Seat - Tvpo of Grout `1
<br /> I ! hrrOshon -/ _._Apls,on. Depth i i Ear+err, Surface Setif Installed by
<br /> Repair Work Dane Kr Type of Pump -,� F; P -_-1_------- Sia+e Work Dnna L4'
<br /> i
<br /> Well Destruction ❑ Well D,emetnr ,^,eallttp Motorial • Depth
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<br /> Depth_ Filler Material G Depth _
<br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR .3POMON i ! DE.STRUCTION I V irvo septic syslem permntad if pubf,c sower !s
<br /> available witmn 200 Ieet.S r,4 I
<br /> Installation wilt serve: Residence— Commercial— O,her
<br /> Number of 4vrng units: �- Number of bedrooms
<br /> Charectar of sell IO s depth of 3 feel: _—,.___.- Water table depth
<br /> SEPTIC TANK ❑ TypelMrg _ ---_ CapaC,ty- — NO- Comparnraa")ts
<br /> PKG, TREATMENT PLT.Cl Method of Dispossi
<br /> Distance u,nearest: Well Foundntirn---�.... F`ropertv Line „....,_ - ,
<br /> LtAr,HINCL LINE UI No. H Length of finds ,_,,.- ._,.—.—__—ww..----�- Tate!
<br /> FILTER 8ED CT Distance to nearest: We;: I joperiv Line -_
<br /> Sf[EPAGE PITS ll Depth -_ J Sire _� _..__ Number
<br /> SUMPS 11 Distance to nootest' Well Foundation-�-,_, Property I ina
<br /> DISPOSAL PONDS U
<br /> t heraoy C"+fy that I have prepared shit apolical,on anti that the no,\ , 1� be(tont,,n accardante w0h San Joaquin county wd,n An GDA, ]tale in Ws, and
<br /> rubs and fegufahons of the San Joaquin County
<br /> Homs owner Or Ir(enyed agent's a+gnature Cart,f e,the'a'ow�ng ..i Ce IdY!het in Ihp ps1orma,,.of the w11114 for vh,ch this permit is,1.susd, I shall not
<br /> amoloy any person in such manner as to beteme subject to wt),k-an a compensation laws of Celdornia' C L%ntractor's hir,np or sub-conrracOng t'ignrtU'•
<br /> Certifgs the f;Mv
<br /> "i Carr• ,that+n the perfLlOf the Work!or ,,h,Ch th,a porm't rt,aeued.I shalt employ pfrapna SUbMCI 10 WWr man's CO,npnnta
<br /> lion taws laTf+e app .ancall r aN I r SKjne - -- _.._ v_-- T rtes. ��- - - - -- Ohio:
<br /> FITMENT USE ONLY
<br />�� A[ry!rCst,r.n/scceor,ro uv _ .+.n-'�+r+.-.,►_..[ ..;-..-�.._ Oate __i�r+w� ?p/,/�{ .-�,,AArrnn
<br /> NI O! Grout Inasrec"n b _._-....._......_.. Date:_ ------ F.,na1 In'rtoct,on.bx_1--- '✓-f •'j'_b.r rte/_ 7n;r. Ltie..LLa r'lf.?
<br /> I'! en n..r urn ,I+ r,s,lr••, , ::nr, J...«-1,:in Cn,.uirp ''ren Lir.M'M It 11 „•e 1, v
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