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APPLICATION <br /> SAN JOAQuIN COUNTY PUBLIC HEALTH SERVICES LDP i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> PHONE (209)468-3420 <br /> } � ` , 5 <br /> STOCKTON, CA OOM 9145520T.oi <br /> Q <br /> J 94 ERM=M IRES I YEAR fROM DATE ISSUED <br /> ' (Complete in Triplicate) �� <br /> Agplicatlon is herct;y made to San Josquin County for s pent= to construct andlor insta=l elle work herein described This <br /> apylication is made in c=zpliance with Sen Joaquin County Ordinance No. 5L9 and 1$62 and the Rules and Regulations of San <br /> �u—in county Public Seslth services. <br /> 14�y crtjfhttyl CMsS -' <br /> Address �,j'i 1 in dG c Ufa b /'i t�Pf C ty CkLot Size�Acresge <br /> �nor s Name !T4 f' 11L&6 QI u n o 1 d S _ _ Address hone - - o70 <br /> QiS'y <br /> Contractor Dc. address UCense No Phone x -3fif-2.Zo <br /> PE OF WELLIPUMP NEW WELL ❑ WELL REPLACEMENt C1 DESTRUCTION ❑ Out of Service We.0 ❑ <br /> PUMP INSTALLATION u SYSTEM REPAIR ❑ OTHER ❑ Ntonitaring Vail <br /> DISTANCE TO NEAREST SEPTIC TANK ��_ SEWER LINES _ ■'fk DISPOSAL FLD AIA. PROP LINE <br /> FOUNDATiGN 25' AGRICULTURE WELL _JL6N--_ OTHER WELL PITS/SUMPS 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Q Industrial © Open Bottom ❑ Manteca Dia of Well Excavation ora of Well Casing <br /> Domastic/Private J.Gravef Pack. ❑ Tracy Type of Casing_ PVC-1 Specificatians o Ve` <br /> Public n other n Delta Depth of Grout Seal tr'�� Type of Grau <br /> Irn � <br /> Qatean �5tpprpx Depth I 1 Eastern Surface Soul tnstailed by� " <br /> Repair Work Done v Type of Pump H P State Work Done _ <br /> all Destruction ❑ Well Diameter Seal:-g Materitl i Depth <br /> Depth _ Faller Material t Depth <br /> T PE OF SEPTIC WORx NEW INSTALLATION I I REPAIR rA001TIt:N i i DESTRUCTION I I INC sapttc system permitted 41 public setwer is <br /> available within 200 feet I <br /> staltation it <br /> serve Residents_ Commercial _ Other <br /> Number of Gvirig units: Number of bedrooms <br /> Charwar of sad to a depth of 3 feet Water table depth <br /> PTIC TANK ❑ Type/Mfg Capacity No Compartments <br /> G TREATMENT PLT ❑ Method of Disposal <br /> Distance to nearest Well Foundation Property Line <br /> CHING LINE ❑ No b Length of bras Total length/size <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line <br /> kSPAGE PITS I I Depth Sue Number <br /> PS LI Distance to nearest Well Foundation Property Lne <br /> ISPOSAL PONDS ❑ } <br /> tliereby certify that I have prepared this application and that the work Nn71 be done in accordance with San Joaquin county ordinances state jaws. and <br /> as and regulations of the San Joaquin Couaty <br /> Nome owner or licensed agent's signature carnifies the following '1 certify that in the performance of the work for which this permit is issued I shall not <br /> oicy any person in such manner as to become subject to workman s compensation laws of Cajifornia 'Contractoes hiring or sub-cantracung signature <br /> 9-tifias the following 1*1 canify that in the performance of the work for which ttus permit.s issuad. I shall employ parsons subject to workman s compensa <br /> n taws of California - <br /> The applicant must calf for all required inspections Complete drawing on reverse side <br /> gnod X AIA&C& Tide Date <br /> FOR DEPARTMENT USE ONLY <br /> �• <br /> 6�'u <br /> '""on Accby DaterGroutInstaactian by Data F%nal Inspection by DateonafCamq <br /> Appii..ant - Return all copies to San Joaquin County public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009. Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED (C]�'AQ[SH[j�t/���! AECEIVED By `rk `DATES, PERMIT NO <br />