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r`' hc, /�•� a ows s smell 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 R IRES 1 YEAR FROM DATE ISSUED <br /> inTriplicate) <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 coWliance 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 (_ t �l-•+. Cit Lot Size/Acre /e <br /> Owner's Name _ �� � � 1 u <br /> Address Phone <br /> t a r _...- <br />�: Contras for ddress � f4«.,1--License No. 7 43 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTIO Out of Service Well ❑ <br /> t PUMP INSTALLATION' ._ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> j DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD-�`r'� PROP. LINEf <br /> FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA! CONSTRUCTION SPECIFICATIONS <br /> vT� <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Z Dia. of Well Casing <br /> j� <br /> omestic/PrivateGravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 1'1 Public El Other 171 Delta I Depth of Grout Seal _ �� 7� <br /> ype•of Grout S <br /> I I Irrigation g' ��Approx. Depth I 1 Eastern Surf Seal Installed by <br /> Repair Work Done L] Type of Pump H.P. Z _ <br /> Well Destruction * Well Diameter Sealing Material S Depth <br /> $18t@ Work Done <br /> .� ep <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION] i REPAIR/ADDITION I I DESTRUCTION 111No'septic system permitted if public sewer is r <br /> t available within 200 feet.) <br /> I_ Installation will serve: Residence Commercial— Other_ 1 <br /> t. Number of living units: Number of bedroomsx # <br /> Character of soil to a depth of 3 feet: y Wate.table depth <br /> SEPTIC TANK: ❑ Type/Mfg Capacity No Compartments <br /> .PKG. TREATMENT PLT.❑ 9 <br /> s •r.MeDisposal <br /> thod-of Disal <br /> _T ; <br /> a_. . <br /> i Distance to nearest: Well Foundation :Property Line <br /> LEACHING'LINE Cl No. & Length of lines ' Total fength/size v J <br /> FfLTER BED ❑ Distance to nearest: Well ' Foundation Property-Line. * 71 <br /> SEEPAGE PITS I I Depth Size r Number <br /> SUMPS Ll Distance to nearest: Well Foundation. *, <br /> Property Line- <br /> DISPOSAL PONDS' Cl <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San'mJoaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County ' <br /> Home owner or licensed agent's signature candies the following: "I certify that in the performance cfghe.work for-which this permit is issued, I shall not f <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 /> dartifies the following: "I certify that in the performance of the work for which this pe,mitmis issued, 1 shall employ persons subject to workman's eompensa- <br /> tion laws of California.' i <br /> a <br /> The applicant irequils:,C�onii)letedrawing on revers -side. Y $ E l <br /> j <br /> r' f ' .� an�• j <br /> Signed itle: � Rate' f <br /> r <br /> FOFWEPARTMENT USE O LY _ <br /> Applicata cepted by 'Dare t1A <br /> r' <br /> Pit Grout I pection by Date�y4' f i`'`` i Dateal lnspecfion byAdditional Comments:Applicant - Return all copie to: San Joaquin County Public Heal.th;Services'��/ (/ <br /> Bnvironmental' Health Permit/ServicesQ "Ilk";+.445 N San 'Jgaquln.; .P t) Box 2009, , CA 95201 <br /> Stkn <br /> FEE AMOUNT DUE AMOUNT REMITTED:3r CK h <br /> NFA CASH ftECEiVED BY DATE PERMI7•N0. <br /> . EH 13-21 IRtiV.1 j It yi , <br /> CH 14-20 <br />