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. APPLICATION. <br /> .. <br /> - ---�;- SAN JOAQUIN COUNTY PUBLIC , SERVICES <br /> F ENVIRONMENTAL HEALTH <br /> DIVISION <br /> L �t� 445 N SAN JOAQUIN, PHONE (209)468-3420r <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> #PERMIT EgPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i <br /> -;Application is hereby made.to San`Joequin County for a permit to construct and/or install the work herein described. s <br /> opplicetion;�is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County lie He th Services. 1 <br /> City�� <br /> r Lot Size/Acreage <br /> � + <br /> Job Address <br /> iPhone <br /> Owner's Name Address <br /> 7q/ 4 T <br /> 1 (�f ���j <br /> License No. Z Phone <br /> Contractor °� Address r <br /> TYPE Of W�L•kl•PU - =-;I�EW-WELL~ -x-"WEL-L--REPLACFAi1EtJTrCI.A.-•r-•DES.T.RUGTfON_O_011t, of Service We11 Ck, <br /> -.—�" -SYSTEM REPAIR C7 OTHER Q Monitoring Well U{ <br /> PUMP INSTALLATION-0 -, f <br /> L FLD. PROP. LINE <br /> DISPOSAL <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINE i■ <br /> FOUNDATION AGRICUL UTUT RF-WELL OTHER,WELL PITS/SUMPS Y <br /> - } I <br /> INTENDED USEr !_'TYPE OF WEL _L PROBLEM-AREA-•-ACONSTFIUCTION SPECIFICATIONS t �.,, • - d /I' <br /> Open Bottom ❑ Manteca Dia. of Well Excavation 'f° Dla.;of Well Casing 1 <br /> Fl Industrial",c 5pecificatiohsw 4Rr <br /> sr Trr:I � s Type of',Casing_ <br /> Casing- <br /> ["I Domestic/Private: ❑ Gravel Pack 0 Tracy 0 Type of Grout <br /> =["1 Public] f,R,A0El Other I I Delta Depth of Grout Seal C / <br /> j .Kirrigation <br /> Approx. Depth I I Eastern SuffaceSedi installed by <br /> Repair Work Do 0 Type of Pump <br /> H.P. tate Work Done 2 <br /> �, Sealing Material A De <br /> WelFDestfi►c n P,�Well Diameter <br /> Depth Filler Iriaterial & Ae th r- <br /> TYPEtF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR!ADDITION I i4 DESTRUCTION [ I aNailabietrw thin 200 feet.) <br /> stem tned if pub lic sewer is <br /> Installation will serve: Residence Cofnmercia' Offer <br /> r Number of living units: 1 Number oi.bedFoams <br /> rj ,s.z. Water table depth <br /> Character of soil to a depth oft feet: <br /> ! No. <br /> TANK 13. Type/ <br /> Mfg � Capacityf Np. Compartments ' <br /> _ Method of Disposal <br /> PKG. TREATMENT PLT.0 <br /> Distance to neo t: fwell's _ Foundation Property Line <br /> t LEACHING LINE S.El No. & L gth of lines c Total length/site <br /> FILTER SED ❑ Di$tan to nearest: Well j Fou ation t i Property-Line <br /> Number _� <br /> SEEPAGE PITS I I Depth Size' <br /> SUMPS LI Distance to nearest: Well - Foundation t Property Line <br /> DISPOSAL PONDS ❑ ^ i,. <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 /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature <br /> which this permit is issued, I shall employ persons subject to workman's compensa <br /> cert-}les the following: "I certify that;in the performance of the work for <br /> tion laws of Califor ie." i <br /> The applicant m t all 1 eq ' ed ins s. Complete drawing on reverse side. l. <br /> Signed. Title: �j _ Date: <br /> / 7�U f�_ <br /> FOR DEPARTMIENT USE ONLY ` <br /> Data Area <br /> Application Accepted by ) <br /> Pit o Grout Inspection by Date Final Inspection by Date <br /> '� - -�, prat s <br /> Additional Comments: <br /> Applicant - Retuin all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services i j <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 } <br /> ' 41 <br /> FEE AMOUNT RUE AMOUNT REMITTED FASB RECEIVED BY DATE PERMIT'NO. <br /> f' INFO 111 <br /> Eh 13.24I1tEV.1/x5) W !Q <br /> EH 14.2e t <br /> k <br />