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5 <br /> 1 <br /> APPLICATION <br /> f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES p�Y�I <br /> ENVIRONMENTAL HEALTH DIVISION p •l, <br /> 445PNOSAN XJOAQUIN, PHONE (209)468-3420 &A Ce/�&T <br /> 2009, STOCgTON, CA 95201NN��p,,�4/V JCAo t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUETfi0 HEq� //VCp �F <br /> (Complete in Triplicate) �NTq,H�Te CE <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein desd' Wffl'S This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and RegulationM San <br /> Joaquin County Publics Health vices. <br /> Job Address ` L City Lot Size/Acreage <br /> ��� r <br /> Owner's Name Address 4+fiSr�► [911{fr1' 1 r _- _ - _ - Phon I <br /> f <br /> —Contractor- - Address- ltml License-No. a(., _961-f hone.116 <br /> f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [-f DESTRUCTION ❑ Out of Service Well <br /> PUMP V STALLATION ❑ r t / SYSTEM AFFAIR OTHER ❑ Monitoring Well ❑ <br /> ..-ptSTANCE-TO`NE.4RtST:"SEPTICTA'NK—" " -SEWER 'L"IVES'— -- -DISPOSAL FI:D.-"""-PROP'-CINE'"""- k <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom r0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack L] Tracy' Type of Casing_ Specifications <br /> f'I Public (i Other _(.1_Delta­.$ Depth of Grout Seal Type of Grout { <br /> I i Irrigation _Approx. Depth I I Easternurface Seat installed by <br /> Repair Work Done 13Type of Pump H,P. ___� State Work Done KPn I AW44 \A <br /> Weil Destruction ❑ Well Diameter tai sealing Material b Depth <br /> Depth r J Filler Material & Depth \ <br /> P _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I ,DESTRUCTION I i iNo septic system permitted if public sewer is <br /> available within 200 feel.1, <br /> Installation will serve:. Residence: Commercial Other <br /> Number of living units: Number of bedrooms,_, <br /> Character of soil to a depth of 3 feet: + Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg ' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ / Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines �� Total length/size <br /> FILTER BED 171 Distance to nearest: Well_ Foundkion Property Line <br /> I' <br /> SEEPAGE PITS 11 Depth Size Number " <br /> SUMPS U1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ , <br /> " (herebicertify 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 followi "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 taws of I ) <br /> L! <br /> The applican call for/.Il required ' s ctions. C late drawing on reverse s' a.. <br /> S <br /> Signed Title: ate: <br /> OR DEPARTMEN SE ONLY <br /> ' Area S a 5 S <br /> "Z <br /> Application"Accepted hY'� - <br /> Date <br /> Pit or Grout Inspection It Date Final Inspection by_`, Date <br /> r <br /> Additional Comments <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> �f Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Boxj2009, Stkn, CA 95201 <br /> E <br /> AMOUNT DUE AMOUNT REMITTED CK ' RECEIVED fly DA)-E PEitM1T'fJO. <br /> NFO <br /> EM 13-TI IREV. iw 51EH 14-ZE t_J � <br />