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a APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Services. <br /> Job Address �E=145 LSA_ ___-_ __ City "L CVV Lot Size/Acreage <br /> Owner's NameAddress Phone <br /> Contracfar l w Address ! !" License N <br /> Xo� �=Phon <br /> TYPE OF WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS :l t . <br /> 111 Industrial ❑ Open Bottom C] Manteca Dia" of Well Excavation j Dia. of Well Casing 1 <br /> F) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ 11 Specifications <br /> 1'l Public !1 f-1 Other fl Delta Depth of Grout Seal_ Type of Grout <br /> I I lnigation —Approx. Depth I 1 Easternm Surface Seal Instalied by <br /> Repair Work Dee L7 Type of Pump H,P. State Work Done_ <br /> Well Destruction p Well Diameter Sealing Material & Depth <br /> Depth! Filler Material & Depth ''J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> J , i 1,.�availabie within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: _ Number of bedEpom <br /> 9 � .... <br /> Character of soil to a depth of 3 feet: !) Water table depth <br /> SEPTIC TANKa�) 'T /Mfg +(-- Capacity/, No. Compartments `rt <br /> PKG. TREATMENT PLT. ❑ `•I`' s Method of Disposal 4GL� <br /> k4 ..� <br /> Distance to nearest: Well�- / Foundation - Property Line ;2;�_ <br /> t: <br /> LEACHING LINE C) No. & Length of lines.,"- �-�� Total length/size- <br /> FILTER BED n Distance to nearest: 'Well Foundation Property Line <br /> SEEPAGE PITS I I` Depth °� }, Size { Number <br /> S6MPS . 01' Distance-to-nearest: „•Well"1 j/Foundation 4 in?a - Property Line <br /> DISPOSAL PONDS ❑ <br /> t <br /> I hereby certify that I have prepared this application and that the Wolk-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 subcontracting signature <br /> certifies the following: 'I-certify that in the_performance of the work.for which this.per.mit-is-issued, I shall employ persons subject to workman's-cornpensa- <br /> tion laws of California." <br /> I <br /> The applicant must call for all r ui dins ctions. Co lets drawing Ireverse side. <br /> Signed Title: ��`�Z t Date: <br /> FOR DEPARTMENT USE ONLY <br /> t /J <br /> Application Accepted by 't ' Date - Area <br /> Pillor Grout Inspection by DateFinal Inspection by Date 2 <br /> Additional Comments: - <br /> Applicant - Return all copies to: San Joaquin County PulYhe Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> --� -- <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY ATE PERMIT'NO. <br /> • EH13-24 IREV. <br /> EH a-26 r 7 <br />