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A.PPLICATI ON <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXP RE I YEAR R E ISSUED <br /> (Complete in Triplicate) <br /> Application 1• hcrel7}r made to Sa,a Joaquin County for a ytrmat to construct and/or Snatall [he vork herein dcacribed Thit <br /> application Is made In toimr,11"Ce vith Ban JoaQuln Co=ty Ordnance Ho 5L9 and 1862 and the Rulesi and Regulations of San <br /> Joaquin County PuDlle Health gervicea <br /> r � � rtot.qz— �� Lot 51re/Ac�tt.ge dG S <br /> Job Address �3 city <br /> Owner t Name SSI Address /�a 3 Glen �-------- <br /> �iic J j, -" ¢one <br /> [o.�v vo- GIC <br /> Gonlractor .4 Hddress <br /> 3233 F Tzcj, cense hoc.5 75-14 �7c}Pnone <br /> WELL REPLACEr�fEhT (1 DESTRUCTIDN G+ out of Service ve11 <br /> TYPE OF WELLIPUMP NEW WELL �� sonitoring Well <br /> PUMP INSTALLATION C SYSTEM REPAIR ❑ 1�►•�cJr�QTHER* <br /> DISTANCE TO NEAREST SEPTIC TANK W-Ar— SEWER LINES '30 DISPOSAL FAD NA-t!. P�OP LINE s <br /> fir PTS/SUMPS <br /> FOUNDATION _�/!� AGRICULTURE WELL OT/HER WELt',(A <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 �j <br /> r1 industrial ❑ Open Bottom ❑ �+tan�eca Dia of well Excovetwn. /� OLa I of Well Casing 'i—I <br /> S <br /> }'Tracy Type of Casing Sc1I.-t L Sp�e�r(rcations> e <br /> (1 Domestic/Prlvace ❑ Gravel PAC k f ez' <br /> I 1 Pub4c 011.er�XTt eat ❑ Delta Depth of Grpul Sisal O — 4�- Tr7e C Grout N <br /> 20 rA ox Depth I I Eastern Surface Soul Installed by °`� t I L <br /> 1 I Irrigation _ Pix <br /> Repair Work Done U Type of pump H P State worts Done ._ <br /> g <br /> Well Destruction 0 Welr Diameter Sealing Material Depthdft � <br /> Depth hiller Material i Depth <br /> yPE Of SEPTICyrvoe <br /> K NEW INSTALLATIO REPAIRIADOITION I I DESTRUCTIQN I I INo septic system permitted it publ-C sewisr rt <br /> available within 2001fNet I <br /> Installation w al Residence T_ Commercial Cifter <br /> Number of frvnng units Number of bedrWrns <br /> Character of $04 to a depth of 3 feet Water table Depth <br /> I <br /> SEPTIC TANK C Type/Mf8 Capacny No Cotf+partrrtents <br /> I <br /> PKG TREATMENT PLT O Method of Disposal <br /> Distance to nearest Well Foundation — Property Line <br /> LEACHING UNE 0 No 5 Length of Imes Total length/size I <br /> FILTER GED 0 Distance ro nearest wen Foundation PropenY Le* <br /> SEEPAGE PITS It Dept 5rie <br /> Number I <br /> SUMPS LI Distance to nearest Welt Foundation <br /> Ptopsrty L.na <br /> DISPOSAL PONDS ❑ I <br /> I hereby CeRrty that I have prepared this appiicatron and that the work vnlf be done in accordance with San JoaQwn county ordrnane@ stat• laws aria <br /> ruing and foguistrons of the San Joaou*n county <br /> Horris owner or bcisnsrtl spent s aapnature ci&nibes the }o4v.ving t Comfy that in the perforrrnance of the work fpr whwt1i this psrrtwt is issued I shall npt <br /> employ any pwson Int Wch manner as to b corme Wbfect to wortman s cort+penadtion laws of CaMornua Contractors hwng W subcontracting signature <br /> Certrfaes the fo4o erog I sanity"t in the perlorme tee or the work for which this pe►mrt ra iswad t shaif arsmptoy tNrspnt Wbtect to workman a cornpansa <br /> hon laws of Cahlomla <br /> The aDpticant/must CM for 0 n"urred WxLPOCUOns CcmDleie dfaw+ng on reverse sale <br /> AL,�—.� �5>s ��f�-f{st- Titleler/5 � Date <br /> 4LSl��Dl G <br /> Srgrsed -� g <br /> OR DEPARTMENT USE ONLY <br /> Application AtZW64 by Date Area <br /> Fin on Grout fnspeciron by Data Final Inapeclwn by Date <br /> i <br /> I <br /> AddnNonal comments { <br /> Appli.-ant - Rtturn all topica to San ,Joaquin County Public Health Services <br /> Envlronmantal liealtli Pcrm1C/3erv1ce5 <br /> 445 N San Joaquin, P 0 Sox 2009 Stkn, CA 85201 <br /> FEE <br /> AMOUNI DUE AMOUNT REMITTEID CASH CK RECEIVED By DATE l PEA&Arr NO <br /> r I �G �:?,? 'l,amu 1 n 7 7 �7/_ r^r�� t-CZ <br />