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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 <br /> PERMIT EgPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is here made to San Joaquin count for pP b3' 9 y permit to construct and/or install the work herein described. This <br /> application is made in com�liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 5T 2- L ' -'2C•A1uL-7-LL AW City _ Lot Size/Acreage <br /> Owner's Name _ -2� Y HQ Address <br /> ®®rr NNll ,f Phone <br /> Contractor It'�FA M!&A _<.0VJ Address��,�6 S- 1J �'`P0License No,S�f4�736 PhoneCS 4�4d <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER Q Monitoring Well <br /> DISTANCE 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications <br /> I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth l I Eastern Surface Sed] Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done, <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> { I Depth Filler Material & Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted it public sower is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feet: �- a / Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Ll Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS It Depth. Size Number { <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 f. <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 /> The appl" ant t call for all requirec ' Complete drawing on reverse side. <br /> Signed XAL Title: _- Date: <br /> FOR DEPARTMENT USE`ONLY r <br /> Application Accepted by SK L Date f F Area 6 <br /> Pit or Grout Inspection by Date Final Inspection by Date1 �3 <br /> Additional Comments: ce LcJCs T <br /> Applicant - Return all copies to: San Joaquin County P blit Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO -7 <br /> EH 14-2 Ir1EY. /K 51 ( t� <br /> EM 1I-ZE <br />