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APPLICATION <br /> f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT ESPIRES 1 YEAR FROM DATE ISSUID <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 Ser ces. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name °^ rAldfess ti " L Phone <br /> � J <br /> Contractor AZ� ddress icense No.` Phone <br /> X�� <br /> TYPE OF WELL/PUMP: NEW WELL O WEL0.L REPLACEMENT ❑ DESTRUCTION O Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> N Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications (� <br /> I'1Public El Other P Delta „Depth,of,G.rout Seal Type of Grout w <br /> 11 irrigation M Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done Ll, Type of Pump H.P. — tate Work Done _ <br /> Well Destruction O ' Well Diameter Sealing Material 1, De t <br /> Depth Filler Material pth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION (if DESTRUCTION;I 1 No septic system permitted if public sewer is <br /> z available within 200 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 /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. OMethod of Disposal <br /> Distance to nearest: Welly ~' Foundation Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED O Distance to nearest: WellDom€ Foundation _21iC Property Line , <br /> SEEPAGE PITS 11 Depth ,Size 3 '^E Number <br /> SUMPS LI Distance to nearest. Well..? Foundation Property Line <br /> DISPOSAL PONDS O l r <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and--, -r <br /> rules and regulations of the San Joaquin CountyI <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 must call for all]mired inspections. Complete drawing on reverse side. <br /> Signed X � / / L/c y <br /> Title: _ Date: I/Ow ' <br /> R DEPARTMENT USE ONLY <br /> Aw /6 .3 a// : <br /> Application Accepted by �O Date Area <br /> r Grout Inspection by Date � j Final Inspection by . i� <br /> � .r& Date <br /> Pi -� <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 AMOUNT DUE AMOUNT.REMITTED CK H RECEIVED BY DATE PERMIT'NO. N( <br /> INFO <br /> . EH 13.21 IREV.+iesrs D /` /!�� /4? <br /> 3 -a f ' <br /> EH 14.20 - {{{ ``CC <br />