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Zia <br /> APPI CAT I'0N <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL-HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 SCANNED <br /> ` PERMIT EXPIRES . 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made•to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made incompliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address '�(�� J,�jb€ �r City Lot Size/Acreage r <br /> Owner's Nam � <br /> �JV � oOYi �lAdrmss / Cslt'"� Phone 0, 4 O f <br /> e �, I <br /> �Er Address' q S dcense No.i3sSl tr Phone« = <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well Gl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ` OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing T <br /> ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ r Specifications -s <br /> ('1 Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout t <br /> I I Irrigation _Approx. Depth 13 Eastern Surface Seal Installed by O.fSt t.P <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l I DESTRUCTION I i Mo septic system permitted if public sower is <br /> available within 200 feet.) <br /> installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI 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, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "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: "1 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 lays of California." <br /> The appllca st ca f all required spoctions. Complete drawing on reverse side. <br /> / <br /> ✓ Signed ` <br /> Title: + PRESIDES Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 9e Date r Area �f 9 <br /> Pi!or Grout Inspection lay Date JC Final Inspection by Date <br /> iZJU <br /> Additional Comments: <br /> Applicant: - Return all copies o: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT pt1E AMOUNT REMITTED CK RECEFV BY DATE PERMIT NO. <br /> INFO CASH <br /> ' En 13,24IREV.t'A5i <br /> 1. EH 14.26 _ _ - <br />