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f r `fig ��� -� - •,} �-� APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTALHEALTH DIVISION <br /> 445 N SAN JOAQUIN, �PHONE (209)468-3420 <br /> P O ,BOX 2009, STOC%TON, CA 95201 ; <br /> f _, <br /> PERMIT EXPIRES 1 -YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San J&quin,County for a permit to construct and/or install the work herein described. This i <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. <br /> Joh Address` � © V],("ho r �O 0.Q _ City 166 ell f t-k— Lot Size/Acreage T Q G/'P__S <br /> Owner's Name Address _ Phone <br /> Address "License jVo:. Phone �� j <br /> Contractor A <br /> ���l + " - _ j <br />�! .. TYPE Of WELL/PUMP: _ NEW <br /> WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Well ❑ i <br /> PUMP INSTALLATION C3SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> D1STA_N_CE-TO NEAREST: SEPTIC TANK SEWER LINES `�" DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 'AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ <br /> C1 Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f:i Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_' Specifications <br /> I'•I,Piiblic 7 •DC7 Other fl Delta Depth of Grout Seal Type of Grout <br /> LI wigation;­ Approx. Depth I I Eastern Surface Seal Installed by <br /> i Repair W6rk Done" CJType of Pump State Work Done , <br /> Well Destruction D Wel! Diameter Sealing Material i Depth <br /> r _ <br /> Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADDITION DESTRUCTION I 1 lNo septic system permitted if public sewer is <br /> available within 200 feat.l � <br /> installation will serve: Residence___._ Commercial Other <br />' Number of living units: Number of bedrooms <br /> r Character of soil to a depth of 3 feet: art Je 2 K rr -0 eu4q Watartable depth Q �• (�\\\ <br /> SEPTIC,:TANK, -I' "O­ .T.ype/Mfg Capacity ? No. Compartments V <br /> PKG. TREATMENT PLT. ❑ Method of Disposal--- <br /> Distance to nearest: Well --Sr Foundation Property Line <br /> LEACHING LINE _0—No. Length of lines Total length/size <br /> .-FILTER-SED' Distance to near- st: Well Fou"ndation - Property Line <br /> f 0 ' "�'" Number otle <br /> t ; SEEPAGE PITS X if <br /> depth �+ Size r- <br />' SUMPS LI Distance to nearest: Well Foundation Property Line' " <br /> l DISPOSAL PONDS D - <br /> I 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 Y{" f_ -A. 1 <br /> Home owner or licensed agent's signature certifies the following: "I'certify that in the performance of the work for which this permrt 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 sob-contracting signature <br /> certifies the following: "I cenifythatin.the performance of the work for which this permit is issued, I shall employ persons subjectworkman's compensa- <br /> tion laws of Calif6mla." <br /> The applicant s call for all r ed i s ctions. complete drawing onyreverse side. - <br /> --� _ S g <br /> signed Title: OLd Date: <br /> A FOR DEPARTMENT USE ONLY r <br /> Ll V(2 <br /> App atlon Acca d by Date Ares <br /> oro. ns"psation by Date Final Inspection by Dots r - <br /> Additional Comments: <br /> Applicant -1 Return all copies to: San Joaquin,County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 85201 <br /> s <br /> FEE AMOUNT DUE AMOUNT REMITTED t 'OrrCASH RECEIVEp Y p 7E PERMIT'NO. _ <br /> INFO <br /> H 13-2t 1REV.t/n sl <br /> ' rto 3 <br /> £H to-25 C <br />