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APPLICATION <br /> LIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY PUB <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> in <br /> Application is hereby made to San Joaquin County for a permit to construct No. 54 sand 1862stall and thee work Rules andeRegulationsdOf Sans <br /> application is made in compliance with San Joaquin County Ordinance No. 5 9 <br /> Joaquin County Public Realth Services <br /> Citys4mk Lot Size/Acreage <br /> 'K Job Address <br /> Address � �r W S� - Phone <br /> Owner's Name <br /> �t 1 <br /> 4l�/Uri ,8t.lt Address l Z3 <br /> Ct✓��` _ 14 License No. r.�------Phone <br /> hConlra'to DESTRUCTION n Out of Service Well ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ Monitoring Well L7 <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR L7 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �- <br /> SEWER LINES �-�— DISPOSAL FLD. PROP. LINE <br /> FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications- - <br /> ' Type of Casing_-_ <br /> (.I Domestic/Private CI Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> I'1 Public (I Other 1"1 Delta <br /> I i Irrioation _Approx. Depth I 1 Eastern H P Surface Seal Installed by <br /> State Work Done - <br /> Repair Work Done L7 Type of Pump Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l 1 DESTRUCTION INailabetic SYSn 200 feet.) if public sewer is <br /> Installation will serve: Residence— Commercial — Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity— <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED 1-1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> will be done in accordance with San Joaquin county ordinances, stale laws, and <br /> I hereby comity that I have prepared this application and that the work <br /> rules and regulations of the San Joaquin County <br /> rtify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I ce <br /> employ any person in such manner as to become subject to workman's compensation laws of Cd,I shall <br /> Contractor's hiring c sub contracting signature <br /> certifies the following: "1 certify 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 applicant must call for all r uired ins ctions. Complete drawing on reverse side. �Z <br /> Signed X� v T' <br /> Title: W/V& Date: <br /> OR Q EPAIII TMENT USE ONCY <br /> Date ^l4 � - Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date Final Inspection by. <br /> Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE CK RECEIVED BY HATE PERMIT'N0. <br /> AMOUNT DUE UNT REMITTED CASH <br /> f <br /> . EH 13.24(REV.I/$15) <br /> f� v -� � 1 a" O <br /> EH 1•-2a 1 <br />