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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SMVICES <br /> ENVIRONMENTAL HEALTH DIVISION r <br /> 445 N SAN JOAQUIN, PHONE (209)468— 4 { � ��? r^ ,� .�'�! <br /> P 0 BOX 2009, STOCKTON, CA 95201 r>, Sr r,BICE <br /> PERMIT =IRES 1_YEAR FR_OM__DATE_ ISSU" VG -3 AM j f: 43 <br /> (Complete is Triplicate) <br /> Application is hereby =&de to San Joaquia County for a permit to construct and/or inets]_L the work herein describe$ This <br /> application is unde is ccupiiance with San Joaquin County Cirdlnance No 500 and 1662 and the Rules and ftegulationa of San <br /> 4oagtt4n Cotmty, Public Health Elervicea <br /> Job Address <br /> C,y Lot Size/Acreage N�r C.✓ <br /> Owner a Namef�'�.0 C [ ' Phofl. -1 <br /> Conttacttu Address 1 � Lo V qMicense No Phone-25 -'2R( <br /> TYPE OF WELL/PUMP NEW WELL-Mrx WELL REPLACEMENT r DESTRUCTION 1 Out of Service Well ❑ <br /> afUMP INSTALLATIO C SYSTEM REJ AIR Z1 OTHER C l onitoring'well <br /> OtSTANCS I'OM$ARIsST,+SEPTIC TXNX SEWER LINE$_ - DISPOSAL FLO, Pf PP LINK-2L <br />"r FC}l�lf�i7A�'3#]Ai `""- PtMGULT`Uk�AYSII.t. 0T'4dR WELL< MTS;'LIMPS <br /> INteND!_D IUSE TYPE OF WELL PF16BLEM AREA CONSTRUCTION SPEtrIFICATI N^a 1j � <br /> L) Industrial ❑ Open Bottom C+ Manteca Dia of Well Excavate n Dia of Well Casi g <br /> NDamestrC�Private ravel Pack �i]Ttacy Type of Casing_{ ��_.___ __-_--_ Specifications <br /> I 1 Public 1-I Other n Delta Depth of Grout Seas 437 Type of Grout <br /> I i Irrigation Approx Depth I i Eastern Surface Seal installed by Irf <br /> Repeir Work Done U Type of Pump k P State Work Done _ <br /> Well Destruction G Well Diameter Scaling YAter ial & Depth <br /> Depth -- Filler Materiel 3 Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system r per iG seswer is <br /> ava,lab! n 40 feet y <br /> Install8tlor" dl'8ervie Residence_. Comrgarclal— Other <br /> Number of INtirriber of bedrooms <br /> 1 <br /> -Cltiaracter of soft to Ji of 3"feet Water table depth <br /> z SEPTIC YANK, _ Q Type Capacity No Compartments <br /> PKG TREATMENT PLT:Q Method of Dtsposal <br /> > Distance to nearest Well n _ _�- Property Line <br /> I EACiiING"LINE CI No b Length of I -_.__-. _ Total len sue <br /> FILTER BED ❑ Distance to rest Well Foundation. Property <br /> "-S6EPAGI PITSI.1__ Size . -._ Number <br /> 4 i 4 <br /> Ulit S y w ams to 44fiur Well Fau tfaaron P,ral3etiY Line <br />_y <br /> f hard'ay oorirfy tiiat f flava prepaead tires applicauon and that the work was be done in accordance with San Joaquin county ordinances, stala laws, and <br /> ' rules hod regufa0ons of the San Joaquin Covnt:yr° I "I <br /> Homeowner or ficerised,ngeoPs signature cerslfiesthe'following 1 certify that in the performance of the work for which this parmit Is issued, I shall not <br /> ' or'nploy.ahy pardon in sua meaner as to become aubloct to workman s compensation taws of California " Contractor'$hmng w sub-contractirg.sranature <br /> Icerufles theiolloyAng "I certify that in the partorMance of the work for which this permit is issued, I shall employ persons subject to workman's companse <br /> tiara taws of catitorrae" <br /> Ytte aplica st c far *eqa inspections Complete drawing on}reeversee slide <br /> R _._ <br /> Signed Title —AA Date q1, 1q,41 <br /> OR DEPARTMENT 115E ONLY r� <br /> A;phcatson AcCaotod ty 4 Data Araa <br /> Pit or Grout tn"clion_by -____ - Date Final Inspection by Date <br />� ��,eltranal Comments � ���_ <br /> Applicant - Return all copies to Sart Joaquin County Public health Services <br /> Environmental Heath Permit/Services <br /> 435 A San Joaquin, F 0 Box 2009, Stkn, CA 8S2t]1 <br /> INFO AMOUNT DUE AMOUNT Rl Mit'1I;t7 CASH RECEIVED By DATE PERMIT NO <br /> tk 13.74,(w I, �s t <br /> EH .4,^6 <br />