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n APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 0jx� <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in "triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/orinstall the vork herein described. This <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 /> Job Addrass '+��` d� i City ` Lot Size/Acreage <br /> Owner's Name �rY r Address __�. C,— _�� -O/`• Phane(U-7-)�V <br /> i <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑- WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service We11 ❑1. <br /> - . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPT SEWER LINES DISPOSAL FLD. PR E <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAFtEA­CONSTRUCTI 1 ICATIONS <br /> ❑ Industrial i# ❑ Open Bottom ❑ Manteca f�Dia. of cavation Dia. of Well Casing�_- <br /> C7 Domestic/Private '3 ❑ Gravel Pack [.Tracy Type of Casing_ Spe`c�licati"�- ons <br /> �= .- <br /> I'I Public I:1 Other `' f 1 pelta Depth of Grotiiai"— f- Type of Grout <br /> _- <br /> I Irrigation �.Apprpx, Depth ! IEastern -� "$i,rface Seal Installed by <br /> P� 'Y i Type Pump <br /> Re rr .Wlrpone U T -�� "�� H.P. + State Work Done_ <br /> Well Destruction ❑ WeDiameter. Sealing Material A Depth i <br /> i Depth Filler Material 3 Depth e I <br /> TYPE OF SEPTIC WORK:: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted it public sewer is <br /> availabis within 200 feet.) <br /> Installation will serve: Resii3 l� r <br /> Number of living unitsNm�br w le -1 Y Il <br /> Character of soil to a depth of 3 f �;;tt: o Water table depth <br /> SEPTIC TANK: ❑ 'Type fNfInit 11 ity E No. Compartments <br /> PKG. TREATMENT PLT. ❑ wor . being coni pl u` "?" <br /> or inopected '"""9ethod of Disposal <br /> Dista f+`t I �st p eWtakTMUMTU11h1IUl1 `iPr6perty Line <br /> LEACHING LINE ❑ .No. & Length of lines Total length/size <br /> . -.. <br /> FILTER BED ❑ Distance to nearest: Well _ Foundation Property Lrne ,I <br /> 3 <br /> SEEPAGE PITS l I' -Depth Size Number <br /> SUMPS L I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ _ t <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 j <br /> rules and regulations of the San Joaquin County <br /> Horne 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 I <br /> certifies the following: "I certify that in the performance of the work for which thisermit is issued, I shall employ p p y persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must ca 1 requir inspe, ions. Complete drawing on reverse side. <br /> Signed Title: Q!•(/] Date: ._ <br /> 77 uory 4r, <br /> S <br /> O DEPARTMENT USE ONLYACy 1 <br /> Application Accepted by A Date <br /> Pit or Grout Inspection by .Date Final Inspection by Date 1i <br /> Additional Comments: j <br /> Applicant - 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 95201 <br /> FEE r <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> • EH 13.24 1NEV.1 m W [3" �[ y lorNo <br /> EH tate ��ll �'n� ig�a_� 411q1­-6?90(01 <br />