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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. 0 BO% .2009, STOCKTON, CA 95201 <br /> i <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. 549 and 1$62 and the-Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ' <br /> Job Address v Cit Lot Size/Acreage C/Q <br /> Owner's Name Vw 6llL raA AddressM1.wCtt/o !(, S/ Phone <br /> Contractor 1 45 z kw Fle(Address YIL- ­ A , 'JSja6, <br /> Sr <br /> License Nog,7 7c 747 .Phone !� 3� <br /> TYPE OF WELL/PUMP:, - NEW WELL 171 WELL REPLACEMENT 171. DESTRUCTION-❑ Out of Service We11 0 <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER 0 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 PROBLEM AREA` .'-CONSTRUCTION SPECIFICATIONS - <br /> Industrial ❑ Open Bottom ...0 Manteca :Dia. of Welt Excavation Dia. of Weil Casing <br /> f f omestic/Private ❑ Gravel Pack C1 Tracy Type of Casing_ Specifications <br /> r = <br /> I'1 Public Cl 0th f1 Delta Depth of,Grout Seal <br /> - - .': Type of Grout <br /> — <br /> I I Irrigation �Appfax. Depth I t Eastern urface Seal Installed by <br /> t <br /> Repair Work Done �Type of Pump H`p- ��. State-Work:Done r <br /> fi Well Destruction ❑ 'Well Diameter Sealing Material&.Depth ' <br /> ' Depth_ - Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I k DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial._.• <br /> Number of living units: Number of bedrooms <br /> Character of $oil to a depth of 3 feet: Water table depth (�] <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property A <br /> LEACHING LINE C1 No. & Length of lines, Total length/six - <br /> FILTER BED ❑ Distance to nearest: Well 'Foundation PropertlKllklhnAA. <br /> SEEPAGE PITS 11 Depth ' Size _ Number A N ffJHHORRAQU N COUNTY <br /> SUMPS L1 Distance to nearest: Well Foundation PUSIG� :•5 <br /> � <br /> DISPOSAL PONDS w p t �W1010N <br /> I hereby certify that I have prepared this application and that the work will 66-done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County . J'.' 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 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 f9r.,all required inspgctions. Complete drawing on reverse side. a <br /> Signed Title: 5�3� F <br /> Date: _ i' <br /> FOR DEPARTMENT USE NLY <br /> Application Accepted by / <br /> Date J fa Area <br /> Pit or Grout Inspection b <br />• pe Y, / Date Final Inspection by <br /> Additions! Comments: <br /> !� <br /> Applicant - Return all copies to: San Joaquin'County Public:Health-Services <br /> W. Environmental Health Permit/Services <br /> q, 445 N San Joaquin, P O Box 2009, •Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERINIT'No. <br /> INFO CA5H �)j z <br /> h EH 13.21 tRtY.1/Ks1 ({ L 6�0 � g" 3 1 �J �J ' 03 <br /> EN Et-26 I <br />