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�..--.�..--:.yam.- -,.ur•,,K,ut—__... -�.�� - k <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENWRONIIENTAL,,.HEALTH DIVISION <br /> ,d 445 N SAN JOAQUIN;'`PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k <br /> (Complete in Triplicate) <br /> Application is hereby made.lince vithuSanCounty <br /> Joaquinfor <br /> County Ordinanceconstruct <br /> No. 549gando1862sand thethe <br /> Rules and.Regulationsdof San6 <br /> application 18 made in compa <br /> Joaquin County Public Health Services. F <br /> City Lot Size/Acreage Lill X <br /> Job Address <br /> Owner's Nam <br /> ' Addres... t <br /> v <br /> 1 d 3 e'%A, ^1 _: --, 4TH h -- Ems- t <br /> ,, .. y S�'�� t � r JEicense fvo; '.."'�f' one <br /> .Contractor Address <br /> TYPE OF WELL/PUMP: j%;NEW WELL 'M WELL-REPLACEMENT 171 DESTRUCTION o Out of Service_ Well ❑. s <br /> ,,� <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitorinfi Well <br /> PUMP INSTALLATIT'v G7 r <br /> DISTANCE 70 NEARE57: SEPTIC TANK _.-.�:�_=---- SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing } <br /> n Industrial Specifications <br /> Type of <br /> LlCasin E. <br /> f",l Domestic/Private ❑ Gravel Pack Tracy <br /> Other <br /> 1-1 n Delta �Depth'of�Grout Seal Type of Grout_ <br /> i"1 Public i v <br /> I I Irrigation ` .-_._ Approx. Depth ! I Eastern Surface Seaianstalled by _ s <br /> Repair Work Done ❑ Type of Pump H.P. '' ^' State Work Done <br /> SealingFllaterial.&-,Depth <br /> Well Destruction i ❑ Well Diameters l f r <br /> i� Filler,Mst=rwel <br /> / Depth 7&:Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION <br /> REPAIR/ADDITION I V DESTRUCTION l I aNailablekw thin 204 featsystem i1led it public sewer ism <br /> instailstion will serve: Residence Commercial Other f '' <br /> _ Number,of living units: Number of bedrooms <br /> Cha <br /> Water table depth of soil to a depth of 3 feet: <br /> 1 r -'' Capacity 1�w No. Compartments <br /> �SEPTIC'TANK ;:w VK Type/Mfg If <br /> PKyG:TREATMENT PLT. Cl x � Method of Disp�ssl `- 0 <br /> Distance_to nearest: --Well Foundation—•> Property-Lina >. <br /> 'd <br /> -GIHIN <br /> Total length/sire - �~ <br /> (LEA' G'LINE X No. & Length of lines <br /> vl, _ ,►v <br /> FILTER BED ❑. Distance,to'near�st: <br /> Well Foundation Property Line ti <br /> . .� __Sue Number. <br /> SEEPAGE PITS <br /> Depth-,,v� v.,4 ✓ <br /> SUMPS LI Distance to nearest Weil _ Foundation�.C—_ Prnper_ty4-ine <br /> " • - > R <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared thii application and that the work will be done in accordance with San";oaquin#county ordinances, state lawand <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's si4nature certifies the following: "I certify that in the performance of the work 4or which this permit is issued, I shall not <br /> - <br /> employ any person in such manner a`s to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that-in the performance of the work for which this permit 4*issuad, I shall employ persons subject to workman's compensa- <br /> tion laws of California." i f <br /> The applicant must call for ail required ins coons. Complete drawing on' eveise side. <br /> r <br /> Signs Title _ �/� — Date: - <br /> �,.. <br /> SE FA DE ONLYAA <br /> 1 �,.Q <br /> Date '1->-_/Area ©2 <br /> Application Accepted by .Y <br /> / i or Grout inspection br - Date Final n by Date <br /> Additional Comments: <br /> Applicant - Return all .CopieS to: San Joaquin County Public Health Service/�w <br /> k Envirohmental Health-P.ermi`t/Services` �(7 5 <br /> f 445 N"San Joaquin, P 'O:Box•2009:; -Stkn, CA,95201 <br /> IFEENFO j AMOUNT DUE AIMOVNT REMITTED R CEIVED BY DATE PERMIT'NO. <br /> , r� <br /> . Em 53-24 Mv,r i A s1 r V <br /> EH 742E <br /> t • <br />