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APPLICATION FOR P <br /> SAN JOAQUIN COUNTY PUBLIC THu ICES <br /> BNVIROMENTAL HEALTH DI <br /> • 445 N SAN JOAQUIN, PHONE (2 420 y3', <br /> P O BOX 200911 STOCKTON, �y5201 <br /> PMIT EXPIRESY <br /> (Complete in Tripli 8 <br /> Application is hereby aade.to San Joaquin County for a permit to construct and/or ioa is <br /> application is all" in tapliance wits San Joaquin County Ordinsxhee So. 549 and 1662 add the Rules and <br /> Joaquin Canty Public Health Services- <br /> Job AedreN /Y f/ o '"'14W AV60W ew. City 5/dcll rlr✓ Lot Sise/Aere✓6e /teV"I�CYIS <br /> owns No" ����Be b�/.'•brrr�l►AN Address "'IV* `� � Phone <br /> CoContractorLl VA&eV S !�Address «A��'�JAI !`'}y�c License No. �a�~rv/ Phone A"��'�!3 <br /> TYPE OF WELLIPUMP: NEW WELL O WELL REPLACEMENT II DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL 0. _ PROP. LINE �- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ open Bottom ❑ Mantaca Die. of Well Escevstion Dig. of WN CasMg <br /> ❑ Oomasticfprrvate o Gravel pack 0 Tracy Type of Casing Spenifications <br /> CI Public C7 other n Dolts Depth of Grout Sad `Type of Grou• <br /> I I Ifrigalion Appro-. Depth I I Eai_W Surface SUM Instdred by <br /> RsPW Work Don 0 Type of Pump H.P, Stat Work Dc's _ <br /> Well Dmin ction ❑ WN Diameter Sealing Material i Depth <br /> Depth Filler Sleterial h Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONY REPAIR 1ADDITION.I I DESTRUCTION I I (No septic sypilm permitted A pobkc sewer Is <br /> • available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other['9_Q,�, !IFOP <br /> Nurnber of Wing testa:__L— Number of hedreomt 0— _ <br /> Character of ale to a dpdh the 3 Het: __et (� Water tattle depth /�• <br /> SEPTIC TANK. ❑ Typo/Meg AI E L i4j" pW 1. Capwit,—Lx—ev No.Caegartmartta <br /> PKo. TREATMENT PLT. ❑ Method Of DispoW <br /> Distance to nearest: VHN. Foundation_ Property Uma <br /> LEACHING LINE OF No. 6 Length of tines ^ %e a otel'longth/sue <br /> FILTER BED O Oiatanrw to nearest: WOO /N' Foundation Property line �•� <br /> SEEPAGE PITS N Depth A��_Sr,a �i'� Nu bdr 7' <br /> SUMPS LI Distance to nearest: WON /_-90� Foundation /Jr' Property Line goo' <br /> DISPOSAL PONDS ❑ <br /> 1 heraby eartify that I have prepared that svpplicslkm and that ea work will be done in accordance with San Joaquin county ordinanc".stab Iwya, and <br /> rWas and r09s"h0ns of the Sen Joaquin Courcy <br /> Hens bwror or hothead agtti s iignsture oOrtRigs the fosorring: "I oartify that in the performance of the work fa which this Perrot sliaated,I ahetl not <br /> ernploY try P&M in ash manner W to bacon subject to workman's compensation laws of California.-Contractor's hiring of sib-contracting siputwa <br /> prdfias the following:"I certily that in the performance of the work to which IN,permit is Isa md,1 shut employ Poni a+blect to WO*"Wn"s COMP tN• <br /> tion Iowa of California," <br /> The pphe4m frr CAN for at rb[tL*"inSpgaion. Complete drawing on reverse si". ` <br /> Signed X Title: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted try C • Oft Arse <br /> 7 <br /> /P�(Alp(fiiout mtpsction by Dab �� Fuad Inspection by _— D•aaa u' . <br /> d.Adstdane Comments: <br /> Applicsnt - Return all copies to: 8a0 Joaquin County Public Health Service <br /> \\ Spvlraoeestal Health Permit/Service. <br /> 1`y NS M eta Joaquin• P O Boa 2W9r 3tknr CA 95 <br /> 01 <br /> Vl� FEE AMOUNT OUE AMOUNT mlio RECEIVED BY DATE <br /> INF_ CASH <br /> . l.M List les'.a n u s I l l 1 13 r <br /> far ma TT <br />