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_ r <br /> F <br /> APPLICATION <br /> 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 MIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> C 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 �� Cit Lot Size/Acreager/ <br /> Owner's Name GLIA LL Address > Phone <br /> Contraclor ` �� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT . DESTRUCTIONOut of Service Well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER 0 Monitoring Well ❑ <br /> _DISTANCE TO NEAREST:.SEPTIC TANK_ SEWER LINES �� � <br /> � DISPOSAL FLD. PROP._LINE, •��- <br /> FOUNDATION AGRICULTURE WELL Q(.� OTHER WELL��PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 46 <br /> KDomestic/Private DRLGravel Pack , ❑ Tracy Type of Casing_ vC Specifications <br /> VI Public 1-1 OtherF1 Delta Depth of Grout Seal . D 1�� Type of Grout <br /> I ! Irrigation ,<?ua Approx. e6tl� <br /> h I I Eastern Surface Seal Installed by tr, <br /> Repair Work Done LJ Type of Pump H.P. State Work 0one_ <br /> 1,fWell Destruction � Well Diameter ,T t! 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 sane: Residence __ Commercial` Other <br /> �. <br /> Number of living units: Number of bedrooms i <br /> l <br /> Character of soil to a depth of 3 feet:. Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> x-w <br /> Distance to nearest: Well Foundation :Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size i <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> --SUMPS "` -n-_t -L I Distance to nearest: Well FoundationPro <br /> ., party Line <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 Is and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cenifies 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 /> canities 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 ryi ust call for all required insPections. Complete drawing on reverse(side. <br /> Signed X. �r/f l Title: hC {C vt <br /> Date: �� /Z <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date -.�4q Z <br /> Area <br /> Pit or rou nspection by .Date � lI� Final Inspection by � Date qn— <br /> Additional Comments: "h Of <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P G Box 2009, Stkn, GA 95201 <br /> FEEAMOUNT DUE AMO T REMITTED CK <br /> IRECEIVED BY ATE PERMIT'NO. <br /> NFO CAS <br /> EK 13-24 <br /> F EH 1426(REV.1i831 <br />