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+- APPLICATION - <br /> SAN`JOAQuIN COIINTY PUBLIC HEALTH SER_ <br /> - - ENy I RONMENTAL HEALTH DIVISION <br /> - 445 N SAN JOAQUIN, PHONE (209)46E-_$§ O <br /> -- — - —� P-07-BOX 2009,—STOCSTON,-CA-9520 <br /> PERMIT �.-'Ir%PIRES 1 YEAR FROM DATE ISSIIID� �C <br /> - (Complete in Triplicate) <br /> lrC <br />' Application is hereby made to San Joaquin County for a permit to construct and/or install the work n. bed This <br /> application is made in cowliance with San Joaquin County Ordinance No 549 and 1862 and the Rules of San <br />' Joaquin County Public Health Services. rfr ss <br /> Job Address Q CitySAOCLtLot Size/Acreage <br /> ��,, Q 2-0qOwner t Name d n , W ddress OX— `O n jPhone 4 <br /> Contractor�r 1 1n-( — Addres- 'T7 t't�1`�[1;C� 7' R License No �r7(Y� Pho s <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service well 0 <br />' PUMP INSTALLATION q SYSTf_M RfPAIR ❑ OTHER ❑ Monitoring well <br /> D1ST^NCE TO riEAREST SEPTIC T.%NK _ y'2 / 1�SE ER SINES 0' DISPOSAL FLO TROP _iNE0 <br /> FOUNDATION �'L AGRICULTURE WELL + OTHER WELL PITS/SUMPS3D—" <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC 10 Lt <br /> Ll industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dta of Well Casing 2— <br /> 'n <br /> asin2— <br /> ,CI Domestic/Private Gravel Pack ❑ Tracy Type of Casing .5 ROGSpectfications <br />' 1 I Public n Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approit Depth I I Eastern Surface Seal Installed by t/ <br /> Repair Work Done L7 Type of Pump Q. H P State Xork Done <br />' Well Destruction O Well Diameter rr Setting Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permuted if public sewer is <br /> available within 200 feet f <br /> 10 Installation wilt serve Residence _ Commercial— Other <br /> Number of kwng units Number of bedrooms <br /> Character of sod to a depth of 3 feet Water table depth <br />' SEPTIC TANK ❑ Type/MfgH Capacity No Compartments <br /> PKG TREATMENT PLT ❑ Method of Dtsposal <br /> Distance to nearest Well Foundation Property Line <br />' LEACHING LINE Cl No a Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest Wall Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> S ren-S Ll vtstance to nearest Well Founaation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that t 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 parnut is issued I shall employ persona subject to workman s compensa <br /> tion taws of California <br /> The applicant must cad for all requrrt►dmidlipaictioons C plate drawing on reverse side a 1� <br /> Signed Title Date <br /> PARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Data Final Inspection by Date <br /> Vd <br /> or Grout Inspection by � /��� /� j,�� ��dit nal o n w<`-^� _C `+c.*e '5VI Loa:) `� 7�1J <br /> Ap as op an y blit Health Services <br /> is <br /> nviroame tal Health Permit/Services <br /> 445 N San Joaquin P 0 Box 2009, Stkn, GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CKit RECEIVED By DATE PERMIT NO <br /> INFO� QZkA_VQ +` CASH ^7 cr <br /> EN 1Y74IREV 1/wyi Z '�� <br /> Em 1425 F <br />