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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> _ <br /> 445PNOSAN <br /> O%J2009INSTOCKTON, CA,95201420 c 'VE(� <br /> L� JUN 16 1 <br /> 93 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED JOAQUIN PUBLIC 9UN <br /> TY <br /> (Complete in Triplicate) EN ONMEN��L MS�RVICES <br /> Application is hereby made•to San Joaquin County for a permit to construct and/or install the work here Tt�,, j s <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations����hh <br /> Joaquin County Public Health Services. /1 ,pp <br /> Job Address T L' fJ0iAl =-- City / Lot Size/Acreage <br /> p � C v� � l� �5 �� CY Phone <br /> Owner's Name Ci e — Address _T <br /> Contractor I'Z �`address d/b� /7� /` License No.-2 <br /> TYPE OF WEL PUMP: ? NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service well Monitoring Well ❑ <br /> PUMP INSTALLATION 8^ SYSTEM REPAIR ❑ OTHER ❑ ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE5__ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 11 Public 1-.1 Other n Delta Depth of Grout Seal Type of Grout <br /> kHrrigation ­Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump L %, H.P. 1.2 L State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_— Other <br /> Number of living units: Number of bedrooms 41", <br /> Character of soil to a depth of 3 feet: Water table depth ((� <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 v <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 or sub-contracting signature <br /> certifies the following: "I 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 app <br /> t must cal all required inspections. Complete drawing on reverse side. <br /> Signed X Title: <br /> �� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Applicetio Accepted t � ��. -.0Date " y�� Area e} <br /> Pit or Grout Inspection by Date te �!Final Inspection by : r � Date( <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 O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK 11 J RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH /J Q <br /> . EH 13-21(REV.r i x s) PA/ f�s 7 �'� fp�� � j �•l �'(��./j/ Z <br /> EH 11.2e / �/ <br />