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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES w -I00�5-152 Acs <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PFIWIT =IRES I YEAR FROM DATE ISSUED <br />' (Complete in Triplicaze) <br /> Application is herein made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance With San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations or San <br />'Joaquin County Public Health Services. <br /> Job Address L+L-*LA sa-I city - Lot Size/Acreage <br /> -r 1 D �s - Phone <br /> Address ' <br />'Owner s Name �r � — <br /> Address License No Phone <br /> V 7 D. M rLntir u i <br /> Contractor lLty;iia��...�r *��<+ � Z- �� ,' ��� '�`;� � 24 <br /> TYPE OF WELL/PUMP NEW WELL L- WELL REPLACEMENT Ci OESTRUCTiON c Out or Service welZ ❑ <br /> PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER 'A' Monitoring Well <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLO <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 'PI:;60GWA14Pfa--� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open 8onom ❑ Manteca Drs of Well Excavation t40 � <br /> , <br /> n Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing $pee+fieerirene— �,.t n r_+ <br />'I I Public II Other n Delta Depth of Grout Seal Wtt� J 1 Ly <br /> I I trit0ation .�Approx Depth l I Eastern Surface Saul Installed by , L C <br /> Repair Work Done U Type of Pump HP e' <br />' <br /> Sealing Mzeria1 i Depth 7i�Tt)t.3A+�Weil Destruction ❑ Well Diameter <br /> Depth <br /> Depth Filler Material t: <br /> -r <br /> ' SEPTIC OF SEPTIC WORK NEW INSTALLATION i I REPAIR/AOOITION f I DESTRUCTION i I INo septic system permitted it public sewer is <br /> available within 200 feet I <br /> installation writ serve Residence____. Commercial — Other <br /> Number of living units Number of bedrooms (f <br /> Character of sod to a depth of$ feet Water table depth <br />'SEPTIC TANK ❑ Type/Mfg Capacity No Compartments <br /> PKG TREATMENT PLT ❑ Method of Disposal <br /> Distance to nearest Weil Foundation Property Line <br />'LEACHING LINE ❑ No b Length of lines Total length/sire <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line { <br /> SEEPAGE PITS I i Depth Size Number <br /> SUMPS Ll Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> '1 hereby certify that I have prepared this application and that the work will be done in accaroance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Homo owner or licensed agent's signature certifies the following I certify that in the performance of the work for which this perrrut is issued I shall not <br /> employ any person in such manner as to become subject to workman s compensation taws of California Contractors hiring or sub-contracting signature <br /> ceniftes the following I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman s compensa- <br /> tion laws of California" <br /> The applicant must call for all required inspections Complete drawing on reverse side <br /> Signed A Title � Date 5f 1U �f <br /> ' YV FOR DEPARTMENT U5>i ONLY <br /> Accepted �-�[ Date _ 7! � � �� L/ Area I D <br /> Application <br /> J + <br />&ddinonal <br /> t or Grout Inspection by Date Final Inspection by Oats <br /> Comments <br /> Applicant - Return all copies to SaJoaquin County Public Health Services <br /> ' Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> fEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO <br /> INFO CASH <br /> et24IREV i,A„ v� pUs�7fl9u OD3Z3U <br /> EM 14>d <br />