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APPLICATION <br /> ` SANZA IN COUNTY PUBLIC HEALTH S$RyjCES. , <br /> ' ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAwiN, PHONE {209}46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT IR IRES I YEAR FROM DATE ISSUED <br /> /� ' ` C� <br /> (complete in Triplicate} <br /> Appli atioa is hery, made to Sad Joaquin County for a permit to construct and/or install the work herein described. This <br /> 9pP1108,tio4 is made in caarpliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and. of San <br /> Joaquin County'Public Health services. gulations <br /> Job Addre _ �. R,��r_ aJeR1r. City a Lot Size/Acreage 3 A<- <br /> Owner's <br /> eOwner's Name ��/U Address Oj LtJ Phone " 6W42— <br /> Contraclo(Woocis IdElh_0_A111_aa9Address)q6,. V_ Ts ,License No-4M440—Phone �Z <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service well ❑� i <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring well i <br /> DISTANCE TO NEAREST: SEPTIC TANK _tfJ� SEWER LINES 9P 12 -� DISPOSAL FLD.1� PROP. LINE' c <br /> FOUNDATION'yS®� AGRICULTURE WELL OTHER WELL_-_ " PITS/SUMPS ' <br /> 4 i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 IndustrialOpen Bottom 15Manteca 'Dia. of Well Excavation Dia. of Well Casing <br /> `Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications <br /> i'1 Public 1-1 Other 1-1 Delta Depth of Grout Seal _r pt Type of Grou <br /> 194 <br /> I i Irrigation .Approx. Depth l I Eastern Surface Seal Installed by .19 <br /> Repair Work Done U Type of Pump -S14-6? H.P. State Work Done ) <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I iNo septic sysiein permitted if public sewer is <br /> 1 <br /> Installation will serve: Residence— Commercial— Other available within 200 feet.l <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: Water table depth ` <br /> SEPTIC TANK p Type/Mfg Capacity No. Compartments -� <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines <br /> Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line ti <br /> SEEPAGE,PITS It Depth Size Number <br /> SUMPS _ !l Distance to nearest: Watt Foundation <br /> Property Line <br /> ,;,DISPOSAL PONDS .j':',. ❑ <br /> `1 hereby certify that I�iave prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la <br /> ✓rules and regulations of the San.Joaquin County ws, and <br /> ,Home owner or licensed agent's ignature certifies the following; "I certify that in the performance of the work far 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 applicant st call for all r ired ins p ctions. Complete drawing on reverse side. <br /> Signed K . e Title: <br /> Date: - <br /> R DEPARTMENT USE ONLY r <br /> Application Accepted by 1. <br /> Date Area d t tv <br /> "Pit orro 'Inspection by Date Final Inspection by <br /> Date <br /> ` Additional Comments: <br /> Applicant -- Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNTDUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> JY. EH6-24t/1EV.i--e,r �� .op �Q 1 ,070© i <br /> EH u•2a 11trJ r !C?o f �� .3� Q <br />