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{ <br /> SAN JOAQUIN COUN`-Y PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 0.7 1— L t �� 445PNOSAN <br /> 0%J 009INSTOCSTON(2 CA ) 420 <br /> 95201c <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servic <br /> f <br /> Job Address " City Got Size/Acreage <br /> Owners Name A I A s l r_�, Phone <br /> 'CUMaof � Wj Addr vt V�/` se N Phon t TYPE OF WELL/PUMP: NEW WELL V��WELL REPLACEMENT C7 DESTRUCTION ❑ Out of service Well <br /> PUMP INSTALLATION ElSYSTEM REPAIR 0 OTHER ElMonitoring Well C7 <br /> r / . <br /> t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE - <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 <br /> f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> C:] <br /> Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing. Specifications <br /> I'I Public fa Vr Fl Delta Depth of Grout Seal Type of Grout ` <br /> I i Irrigation IN Approx. Depth I I Eastern Surface Seal Installed by ' <br /> Repair Work Done 0 Type of Pump H.P, State Work Da <br /> Well Destruction 0 Well Diameter Sealing Material Depth A0 <br /> F • <br /> { <br /> Depth l — Filler Materia�lldr Depth ----_ -- -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is S <br /> f <br /> + available within 200 feet.) <br /> i <br /> Installation will serve: Residence^ Commercial— Other # , <br /> Numher of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: s, Water table depth l <br /> SEPTIC TANK. 0 Type/Mfg Capacity /� No. Compartments <br /> F PKG, TREATMENT PLT. 0 Method of Disposal t <br /> Distance to nearest: Well Foundation Property Lina <br /> 1 LEACHING UNE ,Cl No. b Length of lines Total length/size <br /> FILTER BED.„<_ n . Distance to`nearest: Well Foundation Property Line r <br /> SEEPAGE-PITSI 1. Depth Size Number <br /> I SUMPS LI Distance to nearest: Well Foundation Property Line !` <br /> t DISPOSAL PONDS 0 s <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances-kiate laws, and <br /> rules and regulations of the San Joaquin County - i { 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 subjectto 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 wJrkman's,c�mpsnsa- <br /> tion laws of California." <br /> The applicanift9st call for ui d ' ctic�ns. Complete drawing on rev a side I <br /> Signe Title: Date:l� <br /> 4 R DEPARTMENT USE ONLY <br /> /lpplication Accepted byDate d%�1 !Z Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: 1� q %, ; rr <br /> + <br /> Applicant - Return all copies to: San Joaquin County Public Health Services 4., A �f �!�`�� �R --e <br /> Environmental Health Permit/Services ' <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201_ <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INpFO CASH <br /> + EH1324 IREV.Final '14r 0-0EH11-2a <br /> t <br />