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APPLICATION ---� <br /> SAN JOAQUIN COUNTY PUI3LIC HEALTH SERVICES <br /> ENVIRONMENTAL HF_.ALTH DIVISION <br /> 445 N SAN JOAQUIN,PHONE(209)469-3420 <br /> P O BOX 386, STOCKTON,CA 95201-0388 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSO •D _ Jr �I ..I~~ <br /> (Complete in Triplicate) <br /> Application whereby made to San leatlun Counry fora permit to canstrlct and,'cr insiallthe.work bereia described.This applicatica is m;lde in.nrnplianee with yan <br /> Joaquin Courtly Nvelopmtnt Title Section 9.1110.3 and Sec;tien 9-1115.3 and the Rules aad Regulations of San loacuin County P',Iblic Health Servicu. <br /> �/{7�r�•--�+ f� jam+ �{/� � � <br /> Job Address d //tel /_rte/ / �' l . JL (� (JLI�� r Lot 51 Lr/Acre e <br /> r� C' Y y!S � /�-- <br /> Owner's Nama Address _ Phone <br /> Contac At:dress ,�r j�1r�. 7lydnse Nas�z 3� pne <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT i- DESTRUCTION iJ Out of Servicer well 17 <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER G Monitoring well <br /> DISTANCE TO NEAREST- SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL__. PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PMBLEM AREA CONSTRUCTION SPEGFIC_A_TIONS ry/A�� <br /> El Industral C Open Bottom L) Manteca Dw of Well Excavation_ Dia- gfAV <br /> f I Oomesticiprlvate C Grow!Peck O Tracy Type of Casing_—__- Spe I j <br /> i <br /> I'I Public 1' 011ier l-) Delta Depth of Grout Seal T11T,0r rrl 1! <br /> I IrriUatron _ Approa, Depth I I Eastern Surface Sant Indaned by f,'U <br /> Er <br /> Repair work Done U Type of Pump — ---- H.F. State Work Oone _ &+N—JOAQUIN Cot RrY v 11 <br /> Well Destruction El Well Demeter See.Ltr4 Materia.l a Depth PUBLIC HEALTH <br /> Depth_ Auer Material & Depth "'ULT'•f J 113.-37) <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I 1 REPAIR.'ADDITI'1Nt `DESTRUCTION I I INo seprtc system perindled if public waver s R/t <br /> av rlable wiltn 2w teat-I 1 <br /> Installation will Serve: Reei lenre 7)�N Commercial _ Other <br /> Number of wing vnrts •y— Number of bwkooms <br /> Character of soil to a depth of 3 feet: �' <br /> Water aloin 4epth -.a (\ <br /> SEPTIC TANK4=Ir , Cl TypereMfp ,. cap+rcy__._ No. Comprnrynts \tel <br /> PKG. TREATMENT PLT. ❑ r Method of Disposal <br /> Distance to nearest Well Foundation Property One <br /> LEACHING LINEBZXL No. 8 Length of liras Total length/site <br /> r "\ <br /> ❑ Distance to neared: Well /Z22 FourxiaPropany Lina <br /> SEEPAGE PITS PC Depth Number _ <br /> SUMPS LI Distance to nw.Sst: Well Foundation Property Lina -7 <br /> DISPOSAL PONOS ❑ <br /> I hereby canOY Shat I Naw prepared This application and that the work wilt be done in accordance with San Joequrn county ordinances, state lows, arv' <br /> F"1111116 and regulolrom of the San Joaquin County <br /> No"owner or Ircenand apant's signtsture candies the following. "I Candy that In the pertorrnance of the work for whkh this parmrl is rtsued. 1 shell not <br /> employ any poison in such rrannar as to become subtact to workmen's compensation laws of California " Contractor's hiring or sub-contracting signature <br /> urldrsa me losowtnp; "I certify that in the perforrnsnce of the work 101 which this permit is issued. I shah employ pammit subject to wtakrnan s coerpeAu <br /> tion laws of Cafilornia." <br /> The applicant us 1a s i rsqu.w spec One. t'wnpet drawirtg or�Lewrse side <br /> •� G- <br /> SiQred Title: Dole: / <br /> FOR DEPARTM Nt USE ONLY <br /> Application Accepted by Da10 / - /S : 214 Ana Q7116 <br /> Pit or Grout Impaction by Date _ Fina. Inspection by Q-fl pap ILS,-9 <br /> Addltional Comments <br /> Applicant - Retu:a all copies to: SanJomqumCounty Public Health Semmes <br /> 1 Envuonmtntal health PermillServices <br /> 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95231-U38 �S2-- <br /> INF AMOUNT DUE AMOUNT AfmirTEO„ �ySM I RECEIVED Sy <br /> Ef t}ar IAjV. ant t+ r <br /> n <br /> = <br /> FH 14-M <br />