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APPLICATION <br /> SAN IeAQUIN COUNTY.PUBLIC HEALTH�4RVICSS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> ZMIT ZZEURLIL.1 3W EM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby n"e.to San Joaquin County for a parsrit to construct and/or install the work bereia described. This <br /> spplicatioa is ■ads in 00MUapce with San Joaquin County Ordinance So. 549 and 1962 and the Rules and Regulations of San <br /> Jasquis County Public Ssalth Services. <br /> Job Addnsi S161 _6AAAir,41MD City, "'"Lot Size/Acreage <br /> Owner's No _ 7 1 d , C6 Address !3aj9AAP7tjfVjC Igb ph*M <br /> ContractorUA6 Address 420 0&0 C At ~_- License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL SC WELL REPLACEMENT E i DESTRUCTION O Out of Service weli <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ HER ❑ Monitoring won PK <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES -. DISPOSAL FLU- PROP. LINE ZZ <br /> POUNOATIONAlf- AGRICULTURE WELL OTHER WELLLM,. PITS/SUMPS <br /> INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Open Bottom ❑ Manteca Dia. of WaN E:csystian Dis. of Wel Casing 2 <br /> Cl Oomestia/Priwtw ©Growl Psck 1XTraay Type of CaWng��- �" SpeciReatione <br /> 1'1 P1rWia Ia Other fl DWts Depth of Grout Seal S al„ 0446 of Grout_Q EAC-tr <br /> I I iff4stim 3„a!Approu. Depth I 1 Emom Surface SOW installed by_RI CAf,a.AZ----- - - - <br /> Repair Work Done U Type of Pune H.P. Stale Work Dote <br /> well onuucd m ❑ Wek Mwnetw .� Sealieg fhterial A Depth sEt ti?PrP A rL J141_Depth 240 Piller Material A Depth Ir 0 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 1 i O£STRUCTION 1 I IN*septic sysgm permitted it public sews is <br /> svaiiabie Within 200 fast.! <br /> butaledon wil saism Residence ComwmereW.._^ Other.....,,�.�� <br /> Nuimdw of living units Numbs of bedrooms <br /> Chwacsr of wS to a depth of 3 feet: Wass table depth <br /> SEPTIC TANK ❑ Type/Mfg Capeft No. Compstwunts <br /> PKG.TREATMENT PLT.❑ Method M Dbpftd <br /> Distance to newest: WWI Foundation Property Line <br /> LEACHING LINE C4 No.A of knwrs Toth ktrtpth/ <br /> MTN AEO ❑ Distance to newest: Wd�,., Foundation Prnparty Line <br /> SEEPAGE PITS I I Depth SI" Number <br /> SUMPS Ll Distance to newest: WON four4atiorr Pmperty Line <br /> DISPOSAL PONOS Cl <br /> I henebv *0111v that I have plejo - this appkcation and that the*Wk vA be done in accord rrae With San Joaquin county onkuv oa,cleat own. and <br /> cub end marAnWce of the Sam Jwsgrrirt Coma <br /> H40M owner at Scerised agent's iipRestrre certifies the folowing:"I*wWv that in the Wormanee of the wwk for which this perms is Issued,I alvei♦not <br /> iiolo►any perawt in such teunwter as n became arA*M Io work~'s eomrpensation bee 01 CaWornia."Cotmaetors hiring at*Aoonaw*v signetue <br /> oeftlRes the :"I certify that in the pertanTum a of the work for which this permit is Issued.I t►I►ap ewnpioy persons subject toen <br /> wwkm 's companies. <br /> don lees of •" <br /> The CAI!for ak ins ions' a drswm0 on •side. <br /> Signedr A- Tft: Date: !��✓ <br /> FOR DIPARTIMlNT USE ONLY <br /> Applastion Accepted by '72 <br /> r l DeN43 <br /> Pk or Grout krpsdfon by Dan- IN' <br /> Addltionel Commom <br /> Applicant - Return all copies t : Sam Jaaquia County Public Health Services C�� / <br /> Haviro vestal Health Persalt/Services U v�lp <br /> 443 M San Joaquin, P 0 So: 2009, Stka, CA 8820E <br /> tM AMOUNT OtIE AMOUNT 1111mTTl10 RECEIVED SY DATE PeRMFT'NO. <br /> .� <br /> ( <br /> 1014g �..�yt � 3 t <br /> tet meati /' L IJ-*3 lq3- , <br />