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I <br /> 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 a <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Appliciition 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 ceaopliancie with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.J� f� <br /> Job Address r `er r City `"04 r Lot Size/Acreage k".5 <br /> 5 1I <br /> C l/ I �i� J� 4 Phone <br /> Owner's Name l Address d <br /> Contractor, t� <br /> �� AdAress License No. r Phone <br /> TYPE OF WELL/PUMP: NEW WELL �k WELL.REP0ACEMENT%n DESTRUCTION o Out of Service Well <br /> ❑ <br /> PUMP INSTiALLATIQN SYSTEM REPAIR ❑ t 'r � BOTHER ❑ Monitoring well Ca <br /> I - <br /> DISTANCE TO'NEA-REST:-SEP_TIC.TANK, _ SEW.,ER_LINES-.- DISPOSAL-FLD: =P_ROP.:.LIN.E_`L __ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS f1 <br /> C7 Industrial ❑ Open Bottom 13 Manteca Dia. of Well Excavation= Dia. of Well Casin <br /> /fid�- 5 cifications <br /> >eDomsstic/Private kGravel Pack7l ❑ Tracy Type of Casing__ pe Yrs <br /> I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout C/>tir+x// rrtew • <br /> I I Irrigation "LPA'Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. 2 State Work Done <br /> Well Destruction ❑ Well DiameteSealing Material A Depth <br /> r , <br /> e..w <br /> Depth Filler Material i Depth <br />` TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feat. <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. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 <br /> 1i Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> II FILTER BED 11 Distance to nearest. Well �Founaation Property Line <br /> I <br /> SEEPAGE PITS I I Depth."l Size ` Number " <br /> SUMPS Cl Distancelto nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ �N }.{ x[rte 1 <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 oanifies 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." Contractors hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for.which,this-permitis•isued, I shall erftpldyy parsons subject to workman's compensa <br /> tion laws of California.' <br /> 414 <br /> The applicant must all for all required,inspections. Complete drawing an reverse side. <br /> Signed X�F ✓/'r'�`� - Title: C:�..c / + - Dat0:0 <br /> f R PARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit orPnl <br /> t Inspection by I� e 'J QQ U. Final Inspection by Date <br /> II <br /> Additl Comments: <br /> Applicant --Return all copies to: San Joaquin County-Public Health Services <br /> ��. Environmental Health Permit/Services <br /> I 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> CK 0+ lM 0 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> I . EH 13.24(REV. i K si II �A % 13— 9 1 93-D y <br />