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`- APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Citysr-KN Lot Size/Acreage <br /> Owner's NameAddress -5- / Phone <br /> Contractor. Address&Yf/wslc/v License No`,j6��3�a Pha <br /> TYPE Of WELL/PUMP: NEW WELL E WELL REPLACEMENT M DESTRUCTION L1 Out of Service Well <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 11 Monitoring Well L7 I <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 i <br /> C� Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation pia- of Well Casing <br /> C.1 Domestic/Private 0 Gravel Pack L7 Tracy Type of Casing_ Specifications <br /> I'l Public f-I Other i1 Delta Depth of Grout Seal Type of Grout r' m <br /> Ii Irrigation �.Approx. Depth I I Eastern Surface Sedl installed by i f <br /> Repair Work Done L3 Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material & Depth .. <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION t I REPAIR/ADDITION DESTRUCTION { I (No septic system permitted if public sewer is <br /> available within 200 feet) <br /> Installation will serve: Residence_)OL, Commercial_ Other <br /> Number of living units: �_ Number of bedrooms _.___ f <br /> Character of soil to a depth of 3 fast: _�.a2� ! y Water table depth Avo <br /> SEPTIC TANK A Type/Mfg ` L _T_ Capacity ���N No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> — <br /> LEACHING LINEOUST-n No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well' _ Foundation Property Line <br /> SEEPAGE PITS rl;kSj-I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 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 applicant c I for all required ins pe tions. Com late drawing on reverse side. <br /> Signed Title: __ _. Date:�_16e� /, ' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ff� L , Area <br /> Pit or Grout Inspection by Date Final Inspection by ate <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 Sox 2009, Stktt, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + fWi�7EIREV.�ixSf / /' f1(� 711�7_06, t�� ! 1 J� �/,T q'� <br /> 3 <br />