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APPLICATION <br /> ~ � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)488-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 4 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED e <br /> (Complete in Triplicate) ; <br /> Application is hereby made to son Joaquin County for a permit to construct and/or install the Work herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> " City f k n Lot Size/Acreage <br /> a,rC�-}--�— <br /> Job Address <br /> -;t-eSf Given No. i` � 702677uchz1t Z3ay U Phone951-7347 <br /> ilzc�lreAJa <br /> Owner's Name <br /> 379560 phone 462-7676 <br /> Contracto,Cla?k l&,U, I -2024 E. ChaA;te/L lJrlyLicense No. _ f <br /> NEW WELL WELL REPLACEMENT 171 DESTRUCTION ❑ Out Monitoring Well C7 <br /> TYPE OF"WELLIPU 7P_ SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES — DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK ��- - AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION 1 <br /> C <br /> ` <br /> INTENDED USE TYPE OF WELL" PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing W <br /> Ll Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Specifications On <br /> Type of Casing_. <br /> n Domestic/Private ❑ Gravel Pack ❑ Tracy VP Type of Grout <br /> j I <br /> I-1 Other Cl Delta Depth of Grout Seal <br /> '1 Public <br /> I I I Irrigation _ Approx. Depth 1 I Eastern Surface Seal Installed by <br /> H P State Work Done <br /> Repair Work Done 0 Type of.Pump - Sealing Material & Depth <br /> Wel! Destruction O Well Diameter Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 availablelw thin 206 feetsystem !led if public sowIs <br /> Installation will serve: Residence.� Commercial,.� Other_____�--- <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity--�-- <br /> R. Method of Disposal <br /> PKG. TREATMENT PLT.❑ properly Line <br /> Distance to nearest: Well Foundation <br /> Total.length/size <br /> " LEACHING LINE ❑ No..& Length of lines Property Line��- <br /> FILTER BED 0 Distance to nearest: Well Foundation ^�- <br /> Silo Number <br /> SEEPAGE PITS 11 Depth Property Line �— <br /> SUMPS Ll Distance to nearest: Well Foundation - <br /> DISPOSAL PONDS <br /> I hereby cenify 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: "1 certify that in the performance of the work for which this permit is issued, !shell not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub contracting signature <br /> certifies the following: "Ice t 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 t all f r u' in ns. C p1 s drawing on reverse side. <br /> Title: IZ 42 <br /> Date: <br /> I Signed <br /> I FOR TMENT USE ONLY <br /> Date b— v q,� a <br /> Application Accepted by ` �#1 .C(-„�.�rel/lo <br /> Pis or Grout inspection by <br /> Date Final Inspection by 7v ate r <br /> Additional Comments: , <br /> Applicant - l copies to: San 3oaquin County Public Health Services <br /> Return alcopa"5 <br /> + Environmental Health Permit/Services l �CL <br /> Ii 445 N San 3oaquin, P 0 Box 2009, Stkn, CA 95201 <br /> "E� <br /> FEE K RECEIVED Y TE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED <br /> INFO D f <br /> . EH 13-24IREV.1/n5i �� xt� ��•b <br /> EH 11.26 <br /> I <br />