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E x. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> q ENVIROWIMTAL HEALTH DIVISION <br /> J 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 comliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. i <br /> Job Address 22202 7 Z: --' — City Lot Size/Acreage IqI4 <br /> Owner's Name / L 1 �G�Addrass Phone <br /> Contractor ddress W"a I ,�-�� � License No. .��Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT- DESTRUCTIO t of Service Well ❑ <br /> PUMP INSTALLATION P SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -`' _ DISPOSAL FLD. PROP. LINE 11-1- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL-2-0— PITS/SUMPS ZeV_74- <br /> INTENDED USE TYPE OF WELL PROSLEMAREA- CONSTRUCTION SPECIFICATIONS X. /' <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f Dia. of Well Casing <br /> XDomestic/Private ?'Gravel Pack7 13Tracy Type of Casing, Specifications <br /> C <br /> 1'1 Public 1:7 Other !� / fl Delta Depth of Grout Seal / Type of Grout <br /> - <br /> I I Irrigation pp ok, I pth i I Eastern J&cs Seal Installed by <br /> Repair Work Done U Type of Pump , . H.P. State Work Done �!���� �� g�%1\,is_ <br /> Wall Destruction ,W Well Diameter Sealing fiaterial i Depth/1- <br /> I Depth ' biller Material i Depth � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION l I Wo septic system permitted if public sewar is <br /> ! available within 200 feet.) <br /> k <br /> ' Installation will serve: Residence— Commercial Other y <br /> I Number of living units: Number of:bedioorn <br /> Character of soil to ai - <br /> depth of 3 feet: �" `' �'� Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg r " Capacitym No. Compartments <br /> PKG. TREATMENT PLT.C7 , .i r . Method of Disposal <br /> Distance to nearest: Well Foundation -�Property Line <br /> i- <br /> LEACHING LINE 0 No. 5 Length of lines Total length/size <br /> FILTER BED 0 Distance;to nearest: "Well Foundation Property Line <br /> 9 % r <br /> SEEPAGE PITS [ I Depth t Si:e + Number <br /> SUMPS Ll Distarncato►earrsti i Well ' = t Foundation r Property Lina <br /> DISPOSAL PONDS ❑ <br /> I hereby Certify that I have prepared th� application and thal"the work- Al be done in accordance with San Joaquin County ordinances, state laws, and <br /> f rules and regulations of the San Joaqu n County - "' + " <br /> Homs owner or licensed agent's'signal re certifies the foNowing:� 1 ca NIKSM in the performance of the work for which this permit is issued, litndll not <br /> employ any person in such manner as t 'become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in i is performance ottKe work for which this-permit is issued, l shallimploy persons subject to workman's eornpensa- <br /> tion laws of California." r <br /> The applicar i ► lions. Complete drawing on rover swe. i !� <br /> Signed XTitle: r Date: 2 <br /> f0 DEPAfiTfMENT.USE ONLY j <br /> Application Accepted by -' F Date Arae ® �' <br /> Pit or rout I pection by ✓ Date/ incl Inspacti n by Date 1 f <br /> Additional Comments: `G #"r✓�S/ /-t /% }� - - �'- <br /> Applicant - Returall copies to: San Joaquin County Public Health services <br /> Enviroameatal Health Permit/Servic"ea <br /> 445 N`San`Joaquin,,P O'Box''2009' Stkn, CA 95201.• <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"ND. <br /> . <br /> Em 17-74 IREV.I as) UU9A C `'a—— t I'PtZZ-7 <br /> w � �Z :�*01tr <br /> Err 1426 T t� F 1.110 <br />