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++, APPLICA 1-0R `x'OR PERMIT yt <br /> f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> } ENVIRONMENTAL Y3EALTH DIVISION <br /> ,.., P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 Z�~ I3S6-1'1( <br /> MIT .ESPIRES 1 YEAR PRQ DATT 3SSUSD <br /> (Complete in Triplicate) ST+ 7�SI�P1ts it 1►►�D, Cr►32;' <br /> Application is hereby meds to San Joaquin County for a permit to construct and/or install the work herein described. This ' <br /> application Is made in ccupliance with,San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. Sn SDS@-Pim IPVLE1ptiG/1L Gf�ht (L <br /> Job Address g©t7 MCI- -577 City ._5 N Lot Size/Acreage <br /> Owner's Name 57' 7TMS15PIS MISA 4M72Address &42C /90 d ee7wn}'-`/� _ Phone ""X3 95 <br /> Contracto License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> u <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER Mona a,; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. i, ILC. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / � ; <br /> t <br /> M Industrial 0 Open Bottom O Manteca Dia, of Well Excavation g 1r ,I <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing ' <br /> .I <br /> M Public C1 Other ❑ Delta Depth of Grout Seal -Tppv all 8.0.1 I' <br /> CI Irrigation App(ox. Depth 0 Eastern Surface Seal Installed by IVO _ _hGU <br /> Repair Work Done LJ Type of Pump H.P. State Work Done _ /lam �P�I 'JP-C[JTiw H <br /> Weft Destruction ❑ Welt Diameter Sealing Material i Depth /_)��i_ � PCic-c- i <br /> Depth Filler Material A Depth �'I II III Ic ub u <br /> TYPE OF SEPTIC WORK: .NEW INSTALLATION Li REPAIR/ADDITION M DESTRUCTION CI INo septic system permitted if public'sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms CX) <br /> Character of soil to a depth of 3 feet. �! <br /> P Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> FILTER BED 171 Distance to nearest: Well Foundation Property Line <br /> I� <br /> it , <br /> SEEPAGE PITS I I Depth Size Number i <br /> SUMPS UI Distance to nearest: Well Foundation Property Line' <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, n <br /> rules and regulations of the San Joaquin County I' r <br /> Home owner or licensed agent's signature certifies the foliowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies 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 uired inspections. Complete drawing on reverse side. <br /> Signed Title: gZ06/S <br /> Date: <br /> OR EPARTMENT USE ONLY <br /> Application Accepted by Data <br /> Pit or Grout Inspection by Date Final Inspection by Dater fir. ' <br /> Additional Comments: G O <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES it <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON,'CA 85201 <br /> FEE NFO AMOUNT DUE AMOUNT REMITTED �K H RECEIVED aY PATE PERMIT'NO. <br /> SAr EH 13.74(RFV.i/rt$) <br /> EH',4-26 <br />