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1 <br /> 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 /> f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I _-.. . (Complete in Triplicate) <br /> ApplicatiTINTU-MIMeinunty for a permit to construct and/or install the work herdescribed. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Jot?Address _0-�- . '14qek RaajCity Lot Size/Acreage <br /> • & C <br /> "qLAOwner's Name Address Phone <br /> Contractor it Address Am; k _.License No. Phone <br /> r <br /> TYPE OF WELL/PUMP: 'N W WELL'.❑ WELL REPLACEMEN DESTRUCTION ❑ Out of Service Well <br /> PUMA INSTALLATION%O p rb SY.5TEA+f REPAIR } OTHER Q ori'itoring Nell L� <br /> j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> ` FOUNDATION AGRICULTURE.WELL 'ETHER-WELTrPITS/SUMPS <br /> a INTENDED USE t TYPE OF WELL PROBLEM AREA Cdf STRUCTION SPECIFICATIONS <br /> (� Industrial D Open Bottom 0 Manteca ,r" �A,3i `"of Well Excavation�`'"'� Dia. If Well CasingTN <br /> �N <br /> Domestic/Private D Gravel Pack 0 Tracy Typep cifications <br /> of Casing_ �S <br /> I'I Public hl Other n Delta De¢lh of Grout.-Seal"""` �" �- Type of Grout 0) <br /> 11 Irrigation Approx, Depth J Eastern ' ,StyPrface Soul Installed by <br /> i Repair Work Done U Type of Pump �XffH.P. l-' — State Work pone <br /> I Sealing Material b Depth <br /> Well Destruction O Well Diameter <br /> 9 W f Fillfer Material d Depth <br /> Depth <br /> +, TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION I i (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence --7C&niTtBrcial_-2, .Oiher <br /> Number of living units: -T Numberof bedrooms` <br /> L&� <br /> Character of soil to a depth of 3 feet: wa ,1 <br /> ANT <br /> SEPTIC TANK CI: Type/Mfg Capacity No <br /> PKG, TREATMENT PLT. 0� �� Me oo44 B ist <br /> Distance to nearest: Well Foundation Property LSE <br /> 1N rOUNTY <br /> �Ai�39A- - <br /> r H SF <br /> LEACHING LINE ❑ Nof?, Length of lines Total lengt i SALT <br /> FILTER BED n ; Distance to nearest: Well Foundation f $RQW <br /> NTAt HI <br /> r <br /> SEEPAGE PITS l I _Depth Size Number <br /> f SUMPS- Z---- UE3isIfa—r to nearest: —Well= ^ -!Foundations ----�'-'--PropertV-Lina`� '! <br /> DISPOSAL PONDS 0 9 <br /> I hereby canify 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 r <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of-the work-for-yihich-this permit is issued, I shall not <br /> i, employ any JCalia. <br /> uch manner as to become subject to workman's compensation laws of California:" Contractor's hiring or sub-contracting signature <br /> certifies the "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 " <br /> 1 The applicanl for all requi inspectio s Complete drawing an "91 <br /> side. <br /> Signed X Title: Date: <br /> ' . 4 <br /> FOR DEPARTMESEONL <br /> ., ..: . 4 X35 <br /> Application Accepted by ^`F' Date Area <br /> 4 Pit or Grout Inspection by Date Final Inspection by Date <br /> 4 <br /> Additional Comments: <br /> Applicant - Returnjall copf les to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> j ! 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> i FEECK I <br /> INFO AMOUNT DILE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> rR Gl �y <br /> f EN 13.24IREV;1/rsf <br /> EH t4.2a <br />