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APPETCAT I ON <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 3 ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Applicati6ra is hereby mads to San Joaquin' County for a permit to construct and/or install the work herein described. Thi's <br /> application is made in-compliance�vith San Joaquin County Ordinance -No. 549'and 1662 and -the Rules and Regulations-of San <br /> Joaquin County Public Health Services <br /> Job Address Z`J (e, �`Q _ City d Lot Size/Acreage <br /> Owner's Name VI!f� �f 1? J�()� dress _- 5 Q(SI Phone I � <br /> Contractor "" L (Zdress V1 N_ ST-- License No.4 7 2:Phone 83!3 <br /> TYPE OF WEL PU NEW WELL ❑ WELL REPI.'ACEMENT ❑ DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION P.__ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> —FOUNDATION= -^ ati -AGRICULTl1RE WELL- ._ "'OTHER WELL <br /> PITS/BLIMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing d <br /> ['I Domestic/Private ❑ Gravel Pack n Tracy Type of Casing- Specifications .._. <br /> 1"1 !>d5r1c 1-1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> Irrigation Aptxox:,0ept Eastern Surfa-e%Saul Installed by <br /> Repair Work4 Done 0 T r `` w� <br /> ype of Pump V H.P. ��(�- State Work Done l� <br /> Well Destruction 0 Well Diameter Sesling Material 6 Depth <br /> Depth Filler Material is Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I ' REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is <br /> available within 200 feet.1 <br /> Installati6n 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. o ' Method of Disposal <br /> '�_ � Distance to_nearest:_SNelt. ,F.oundation" _P.roperty_Line <br /> LEACHING LINE ❑ No. & Length of lines f. Total length/size, <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line RiEeEMVE <br /> " F E 0 ? <br /> SEEPAGE PITS 11 Depth Size Number MLJLAQU1N CC)UN <br /> SUMPS Ul. Distance to nearest: Well Foundation Property Line UBLIC jiEALTjq �Ff�Vll.S <br />.�' DISPOSAL PONDS,.—-L7 _ y � r �;... . . MEN TAL­HfAfrTt `71t7f al>id <br /> f 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 /> E The applicants ust call r all required ins pections. Complete drawing on reverse side. .. <br />"R Signed Title: Date: <br /> FOR DEPARTMENT USE ONLOr <br /> t <br /> Applicata Accapted by Date fV Area f Z� <br /> Pit or Grout inspection by � Date Final Inspection by Data � <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental <br /> Joaquin, P 0 Box2009 <br /> 445NSanPermit/Services <br /> Stkn, CA 95201--J <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATETE <br /> PERMIT'NO. <br /> E13"20IREV.1/Msl <br /> EHN 1{.2E <br /> E <br />