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APPLICATION <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> !� ENVIRONMENTAL HEALTH DIVISION <br /> 445W SAN 'JOAQUIN, PHONE (209)468-3420 <br /> p P 0 BOX 2009, STOCKTON, CA 95201 <br /> 3 PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> (Complete in Triplicate) <br /> Application is hereby Invade 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 Services. <br /> �r i <br /> Job Address .16 `f <br /> 'a I �L���^ City L" of Size/Acreage <br /> 1 pwner's Name �tJ�L Address !1296 eza1 /�� Phon <br /> -7-16V57'0't-770 575- <br /> ntractor �N Address License No. Phone <br /> YPE OF WELL/PUMP:. r NEW WELL ❑- WELL REPLACEMENT C7 DESTRUCTION ❑ Out of service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring well C7 <br /> DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> k INTENDED USE .;,TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ �1 <br /> F] Industrial l7i Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _^ <br /> Cl Domestic/Private - ❑ Gravel Pack C] Tracy Type of Casing_ Specifications "��: <br /> I'1 Public lel Other Cl Delta Depth of Grout Seal Type of Grout <br /> I } Irrigation .Approx. Depth I I Eastern Surface Seal Installed by (y� <br /> Repair Work Done 0 Type of Pump H.P. State Work Done ` <br /> Welt Destruction El ell Diameter Sealing Material i Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l' I RE NW <br /> DST k3C s tem permitted if public sewer is <br /> I� a ai % e n 200 feet.! <br /> Installation will serve: Residence— Commercial 0s iher { <br /> Number of living units: Number of bedrooms r��m� G�� � I�'ed <br /> lLoVi <br /> I Character of soil to a depth of 3 feet: -wark h hind �+t`tfiPlF11003A nr rhon- table depth <br /> '. SEPTIC TANK ❑ Type/Mfg by m $papit N Compartments <br /> i III :.:L l <br /> PKG. TREATMENT PLT. ❑ 'MSfi5od of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total lengthtsize <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 IDepth Size Number <br /> SUMPS LI Distance to nearest: Well' Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certity 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 California.' <br /> The applica must callspections. Complete drawing on reverse side. <br /> Signed X Title: riv ce, Date:, <br /> �. OR DEPARTMENT USE ONLY <br /> 4 <br /> Application Accepted by Date Z <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return kll copies to: San Joaquin County Public Health Services _ <br /> i >r Environmental Health Permit/Services r "..w: " " 'mac <br /> 1'' 445 N San Joaquin, P 0 Box 2049, Stkn-,_CA�95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED At H RECEIVED BY DATE PERMITNO. <br /> o. � II <br /> EH t -2� x <br /> EHiy <br /> ro0�47D 71 ©� <br />