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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EMIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 6, City L49)m Lot Size/Acreage _ if scl <br /> Owner's Name '� e Z R y „g��_ Address Phone <br /> Contractor 012- —Address License No. j5`�4 _Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L 1 OTHER C Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r_- industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications - <br /> 97, <br /> i'l Public C7 Other n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _.Approx. Depth i I Eastern Surface Seut Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Materiel i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I ) REPAIRIADDITION K DESTRUCTION 111No septic system permitted if public sewer is <br /> Installation will serve: Residence_,�C Commercial_ Other available within 200 feet.; <br /> Number of living units: —L Number of bedrooms _>1 _ <br /> Character of soil to a depth of 3 feet: �6.0r_ Water table depth <br /> SEPTIC TANK $ Type/Mfg Capacity <br /> —_C�. No. Compartments <br /> PKG.KG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of Tines r <br /> Total fengthfsize <br /> FILTER BED Cl Distance to nearest: Well— f Fourtdation See i Property Line <br /> SEEPAGE PITS I I Depth _ Size__=)i #-3 Number <br /> SUMPS *4 Distance to nearest: Well ` r <br /> Foundation_ _,,,— property Line32 <br /> _ <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wilt 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 taws 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 app7ZnZ:7F= <br /> rawing on reverse side. <br /> Signed Title: <br /> Date: - G: -93 <br /> �7 FOR DEPARTMENT USE ONLY <br /> Application Accepted by I Ad-. Date 3 Z <br /> Area <br /> Pit of Grout Inspection by Date— �`�'/ <br /> Final Inspection by Date_ <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services ,[�' <br /> 445 N Saes Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK ! <br /> INFO CASH RECEIVED By DATE PERMIT�NO. <br /> EH+ EH 13.24(REV.+i n 5� L {tom <br />