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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 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 vork herein described. This <br /> with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> application is trade is compliance <br /> Joaquin county Public Health Services. City t c3 <br /> �.'T7`x! 7Lot Size/Acreage . <br /> �_ AM <br /> 12L-- <br /> Job Address <br /> '! Phone ! <br /> Owner's Name _ Address <br /> T�q n)CiaO C�1c`a1A1C-A <br /> Contractor �t <br /> aA�r<2 - i pAddress 112 7c +2.+ rL License No. (pC�`� _Phone <br /> TYPE 0f WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well + <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ /�.�., <br /> OTHER Monitoring W 1.1 <br /> _ SEWER LINES -- <br /> DISPOSAL FLD. _ PROP. LINE ]Safes ( <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION -�-_ - AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS Lv7 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ Dia. of Well Casing <br /> n Industria! ❑ Open Bottom i7 Manteca Dia. of Well Excavation <br /> Type of Casing A h} _ Specifications..114 -- ; <br /> n Domestic/Private ❑ Gravel Pack ❑ Tracy S/ Type of Grout "5 I <br /> i'1 Public !l Other C-1 Delta Depth of Grout Seal <br /> I I Irrigation Approx. Depth I I Eastern Surface Saul installed by <br /> H P State Work Done _ <br /> Repair Work Done U Tyt>e of Pump & �r � ! I) . <br /> Well Destruction ❑ <br /> �i�-[FrDiameter Sealing B0'�rial i Depth '�x�. �rA "` <br /> Filler Material i Depth <br /> Depth <br /> system <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIRIADDITION I I DESTRUCTION I I (Nailabetiwthin 2001eetttlsd it public sewer is <br /> Installation will rve: Residence— Commercial— Other S rrS/ a C����AL <br /> Number of living un Number of bedrooms <br /> Character of soil to a de f 3 teat: <br /> Water table depth <br /> SEPTIC TANK. FO-) Type/M g` 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 lengthtsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Weil Foundation property Line <br /> DISPOSAL PONDS ❑ <br /> application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this <br /> rules and regulations of the San Joaquin County i4 issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit <br /> employ any person in such manner as to become aublect to workmen'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, l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applieant mu tali for all requi dins ctions. Ca late drawing on reverse side. <br /> Signed <br /> Title: .�G�Gc'Y Date: �•� / gz' <br /> FOR EP MENT USE ONLY <br /> Application Accepted by <br /> Date r- Area <br /> Pit or Grout inspection by Date F' at Inspectio by Dat <br /> Cd GI <br /> Additional Comments: <br /> � � <br /> Applicaat '- Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit2Seerrvices 009, Stkn, CA 95201 <br /> 445 N San Joaquin, O <br /> FEECK RECEIVED BY DATE PERMIT'No. <br /> ��IN�Fy/Q� AMOUNT DUE AMOUNT REMITTED <br /> Zia- <br /> . EH 13.24(REV.+/N Sl <br /> EH 14.28 �/ <br />