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11 APPLICATION } <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> m . ENVIRONMENTAL HEALTH DIVISION , x <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> RECEIVED <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> S E P 14 1952 <br /> .} PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED <br /> (Complete in Triplicate) SAN JOAQUIN CIUf1TY <br /> P PUBLIC HEALTH SERVICES <br /> '7►pplicntioa is her made to San Joaquin County for a permit to construct and/or install the vo PNVI YlE*frerrri�eb •vlIlIV <br /> application is made in com''Pliance With San Joaquin County Ordinance'lfo. 549 and 1862 and the ]Rules and Regulations of San <br /> Joaquin County Public Health Services. n <br /> Job Address Val ' '"" I r City Lot Size/Acreage <br /> Owner's.Name Y e Address -`&5 Phone <br /> f �y <br /> Contractors ' 4 rkAddress '' IOi %� _License No. Phone VV <br /> TYPE OF WELL/PUMP: = NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well .❑ <br /> PUMP INSTALLATION Me SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> W DISTANCE-TO-NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL=FLD: PROP ,LINE. --� -f <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (.?,Domestic/Ptivate Ci Gravel Pack n Tracy Type of Casing. Specifications , <br /> Il Public E7 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation __"Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done V Type,of Pump 1LL� H.P. S to Work Done �•,, <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth p�,d1�1 <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION i ! DESTRUCTION I I INo septic system permitted if public sewer is <br /> i,,, available within 100 feet.) <br /> Installation will serve: 'Residence— Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> x =SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 `; ',. "6., Method of Disposal <br /> `. Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED ` ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS I I Depth Size Number <br /> �'�a. �_� _ Y . <br /> SUMPS " " -C'I Distance to. nearest: Well' " " "Foundation' Properfy Cirie <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, a <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 work rnan's'compensalion laws of California."Contractor's hiring of sub-contracting signature <br /> *1 certifies the following: "I conify,thet 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 calf for all wired inspections. Complete drawing on verse side. "' f "`�'��` <br /> ' Signed Title: Dots: / - C <br /> F F Ii DEPAftTMENT E ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection � Detr1� <br /> Additional Comments <br /> Applicant - Return all copies to:. San Joaquin County Public Health Services <br /> Environmental Health Permit/Services ? <br /> �.r 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0. <br /> tNFO CASH <br /> . EH 13-24(AEv.1IN51 vV.� -i � <br /> EH 14.75 ' <br />