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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC AI@& VIC d <br /> fad.M a� <br /> ENVIRONMENTAL HEALTH I +■ � .rM.trr <br /> a - 445 N SAN JOAQUIN, PHONE ( 3420 <br /> Oil <br /> $0 , �O P 0 BOX 2009, STOCKTON,� jj� 3 <br /> PERMIT EXPIRES 1 YEAR FROM <br /> a (Complete in Tripli 1 <br /> Application is hereby made to San Joaquin County for a permit to construe e his <br /> application is made in coWliance with San Joaquin County Ordinance No. 51+9 and 1 en t e Au cs and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address �f • (City `y] Lot Size/Acreage <br /> Owner's Name �ddcf1 !16 _ .f�07.U7�. Address z y��• I Phone `� <br /> /4, 5 d' <br /> Contractor Address5�5 License leo. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT)( DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATIIOON� �❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Hell <br /> DISTANCE TO NEAREST: SEPTIC TANK 5/ , SEWER LINES DISPOSAL FLD.s PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I C-] Industrial © Open Bottom © Manteca Dia. of Well Excavation 7, ' Dia. of Well Casing <br /> Domestic/PrivateI Gravel Pack )d Tracy Type of Casing_ ���'� Specifications «t� <br /> I"1 Public 1.7 Other H Delta Depth of Grout Seal f T pe of Grout <br /> I I Irfigation — Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P, Sit Work Done r , <br /> Well Destruction Well Diameter 's Sealing Material & Depth V <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION�97 m permitted if public sewer is <br /> R l 906 feet.) <br /> Installation will serve: Residence_ Commercial_ Other AR � � 193 .1•`l� <br /> Number of living units: M <br /> Number of bedrooms 1 1 J <br /> Character of soil to a depth of 3 feet: �' SAN 10AQtt ih <br /> SEPTIC TANK 0 Type/Mfg Capacity PUBUIC HEAT <br /> PKG. TREATMENT PLT:0 ENVIR�A et ad of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED D Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C1 <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 of 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 "ust call for all r uire spe.ctions. Complet -drawing o arse side. �1 <br /> Signed X Date: -7 -[ <br /> FO DI <br /> PA ENT USE ONLY <br /> Application Accepted by Date ' Area Z f <br /> Pit or Grout Inspection by Date Final Inspection by �+ Date `�r <br /> h <br /> Additional Comments: grl <br /> y37OrSR-00&-57'0- MVV a15'7 <br /> Applicant - Return all copies to: San Joaquin Cou ty Public Health Services <br /> Environmental Health Permit/Services <br /> (j� -7 445 N San Joaquin, P O Box 2009, Stkn, CA 952 1. <br /> T3 r O <br /> INFO AMOUNT UE AMOUNT.REM ED ASR 11 RECEIVED BY DATE PERMIT'NO. <br /> 43bI W <br /> • <br /> EH 13-24 IA .v w 51 <br /> EH r{-2e <br />