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fi!. <br /> APPLICATION / <br /> SAN JOAQUIN CO�+I� ,"�' <br /> PUBLIC HEALTH SERVICES <br /> ENVIROHEALTH DIVISION , <br /> 445 N SAN JOAQU! PHONE (209)46$-3420 w <br /> P 0 BOX 2009,i,"STOCKTON, CA 95201 <br /> " Ij PERMIT EXPIRES 1 <br /> 'EAR-.FROM DATE ISSUED f <br /> (Comp'lete in Triplicate),, i <br /> Application is herebyimade.to San Joaquin County for a permit to construct; and/or install the work herein described. This . <br /> �applicatio>x is mad, in compliance with San Joaquin County Ordinance No. 50 and 1862 anis the Rules and Regulations of San <br /> Joaquin county Public Health Services. <br /> Got Size/Acreages <br /> l <br /> City job'Address <br /> 77 <br /> V Address Phone 1 <br /> -� Owners Name � Cf� ��] ' 3 <br /> i ''.I <br /> No � tq� p <br /> Address . � hone <br /> 'Contra'adr a f` <br /> e NEW WELL ❑ WELL REPLACEMENT ❑ DESTRLVCTION L� Out.of Service Well L1 <br /> I TYPE OF WELL/PUMP: F Monitoring:Well' <br /> SYSTEM REPAIR �OFHER ❑ <br /> PUMP INSTALLATION (❑ . <br /> DISPOSAL FED. ' PROP. LINE ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES l:<A, <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS _._.1" ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> r❑'lndustnal O Open Bottom L'7 Manteca Dia. of Well Excavation b..« �. <br /> fa Domestic lPrivate Ell,Gravel Pack ❑ Tracy Type of Casing� - Specifications. _ A <br /> Type o1 Grout <br /> I'1 Public 0 Other n Delta Depth of Grout Seal I 1 <br /> ' I I irrigation " Apprax. Depth I I Eastern Surface Seal Installed by <br /> -Repair Work Done LJ Type of Pump H.P. Sta4e Work Done <br /> Well Destruction ❑ Welt Diameter Scaling Material & Depth <br /> Depth Filler,�9ate31a3._& Depth <br /> {TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION 1 I INailseptiable w thin 200 permitted it public sewer i+ <br /> Installation will serve: Residence'i Commercial — Other <br /> I Number o#�living units: Number of bedrooms <br /> Character of soil to a depth.of-3 Jeet: Water table depth <br /> Capacity No. Compartments <br /> SEPTIC TANK. ❑ Type/Mfg <br /> 1PKG.iTREATMENT PLT. ❑ .ri Method of Disposal <br /> Distance to nearest: Well Foundation ' Property Lina <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> i FILTER BED f7 ;Distance to nearest: Welt Foundation Property Line <br /> SEEPAGE PITS 11 'Depth Size Number �'.IC <br /> SUMPS . LI Distance to nearest: Well Foundation Property Line (b <br /> 'DISPOSAL PONDS 0 <br /> f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Paws,and <br /> rules and rigulations of the San Joaquin County <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 no <br /> ff employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur <br /> j certifies the following: "I certify that in the performance of the work for which this parmit is issued, I shall employ persons subject to workman's compertisi- <br /> tion laws of California." <br /> The applicant muss call for all required inspections. Complete drawing on reverse side. <br /> iTitle: G <br /> Sign d Date: <br /> .� FOR DEPARTMENT USE ONLY _ � -• <br /> Application Accepted by <br /> Date Afea� Z12- <br /> 17- <br /> �-.�- -. <br /> l Pit or Grout Inspection by Date Final lnspection by ata §LZ�42-, <br /> i , <br /> I Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> f II Environmental Health Permit/Services �` f <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> :t <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY :kit PERM47"NO. <br /> F INFO EI 1 r/y�{J�EH 13-24(REV.I/K51� !I` l� � `—l/r <br /> t EH 14-26 ���JJJ IIS <br />