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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 O 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �/1\/�\J/�� ��\) <br /> Job Addressi; �';�d�� 9 City_t�?1_L� Lot Size/Acreage <br /> Owner's NameAddress Phone F�2!! <br /> Contractor AddresS �LL1L'1�/'/�_�-�zVcense Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION o Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I"I Public (-I Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is S <br /> available within 200 feet.) =1T� <br /> Installation will serve: Residence X Commercial_ Other P <br /> Number of living units: _I-- Number of bedrooms_a <br /> Character of soil to a depth of 3 feet: /A �_ ynAES41—=_� Water table depth <br /> SEPTIC TANK g(1S7 !l Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines AID � Total length/size 2 <br /> FILTER BED O Distance to nearest: Well Foundation ��. Property Line <br /> SEEPAGE PITS Depth Si:e L;Y q,K �� Number <br /> SUMPS 1SX1 51-7-"' LI Distance to nearest: Well lfJCLs Foundation /._2t! Property Line <br /> DISPOSAL PONDS O /Do , <br /> 1 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 must call for all required in ctl ns. Complw drawing on reverse side. <br /> Signed X L�2­!Jx Title: � Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date 1—)4-19,3 Area ° <br /> Pit or Grout Inspection by Date Final Inspection by Date 2Y <br /> Additional Comments: ?� II <br /> Applicant - Return all copies to: San Joaquin County Public Health Services N) ,P- <br /> Environmental Health Permit/Services 1w,-4,K (/AtV?_ 1;4— 14-kI <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 9520 S Y� f/2 YJy 3 <br /> Kl�. <br /> AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> • EH 3 24 EH 73.24IREV.rixs� . to/ <br /> o w �J -® l <br /> r <br />