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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <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 in compliance with San Joaquin County>Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ; R �.�,r 7. <br /> Job Address City Lot Size/Acreage <br /> Owner's NameTA Address f7 s E &24 dig I&725 � Phone <br /> Conhactor / G Address I � <br /> T0r ! License NoC Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WE1.LL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 - OTHER ❑ Monitoring Well L3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` DISPOSAL FLS. .•PROP`.":LINE`"" <br /> FOUNDATION AGRICULTURE WELL _!OTHER WELL PITS/SUMPS, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` <br /> Cl Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation' -_- 'r Dia. of Well Casing �F <br /> f� <br /> [] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ;Specifications QP <br /> I'1 Public 1-1 Other f1 Delta Depth of Grout Seal JT po of Grout 0i <br /> I i Irrioation _.ApprdK. Depth l I Eastern Surface Seal Installed by <br /> 'Repair Work Done LJ Type of Pump H.P. State Work Done _ <br /> Wall Destruction ❑ Well Diameter Sealing Materiel 3 Depth <br /> . ,r `` <br /> Depth Filler Material & Depth I _ <br /> TYPE-OF SEPTIC WORK: NEW INSTALLATION^ REPAIRIADDITION I-1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 300 feet.) <br /> Installation will serve: Residence! Commercial Other �� °�*r _ :`"' <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: - 143 Wati r labie depth 1 <br /> SEPTIC TANK 0 Type/Mfg Capacity : No. Compartments <br /> PKG. TREATMENT PLT. ❑ r' (Method_of'Di'sposal }` <br /> Distance to nearest: Well Foundation ' 3 _ PropertVT Line - <br /> _ <br /> LEACHING LINENo. & Length of lines — y _ Tiitel length'lzize <br /> FILTER BED - ❑ ,Distance to nearest: WelllFaundation Property Line ; <br /> SEEPAGE PITS 11 Depth Size Number,/ " <br /> SUMPS Distance to nearest: Wellt'� -oundation /Oy F•Propsrty Line s��f <br /> DISPOSAL PONDS ❑ v._. <br /> I hereby certify that I have prepared this application and that the work will b@ done,in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County � '• ; i <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 ot-California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance Pof 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 I requifpd inspections. Complete-d(swing-on-reverso-side" <br /> .Signed X__-_ Title: L�A- - Date: <br /> r FOR DEPARTMENT USE ONLY <br /> Application Accepted by Daie [� r Fr!�Q3 Area <br /> Pit or Grout Inspection I Date �Finsl Inspection by ICLP) Date 6/-11 <br /> J' � •° I y <br /> Additional Comments: --- <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009:;_ Stkn, CA 95201' <br /> v�....-.... - INFEeFO CK <br /> „ « �� C4�SrF <br /> —RECE1VEDDrA�TE� ,PERMIT'-NO._ <br /> EH 17.24IREV..1M5r � �3 /0 <br /> EH 11.2E <br /> i <br />