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APPLICATION Y <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ��� <br /> ENVIRONMENTAL HEALTH DIVISION EIIT' <br /> 1445 N SAN JOAQUIN, PHONE (209)46$-3420 RECEIVED <br /> P 0 BOX 2009, STOCKTON, CA 95201 N 193 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN <br /> COUNTY <br /> TY <br /> (Complete in Triplicate) ENVIRONMENTAL <br /> HEALTH SERVICES <br /> 1. ONMENTAL HEALTH D <br /> Application is hereby made.to Safi Joaquin County for a permit to construct and/or install the work herein described• ttfi�6ON <br /> application is wade 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 Address N City t- b l Lot Size/Acreage <br /> Owner's Name 4:90�� KEIZI-V Address 2-130 w-SA69l,C-. " . Lail Phone 96 2-2-- <br /> Contractor T 5-€LF Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER )( oniitoring Well [3 <br /> COOVA1,406 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE /e6p/iie <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREAC S RU'CTIO S CIFICA 0 S -� � ' <br /> f_1 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> 177 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other i-1 Delta Depth of Grout Seal Type of Grout <br /> XI Irrioation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done v Type of Pump H,P. _�— State Work Done ka <br /> Well Destruction ' ❑ Welt Diameter Sealing Material i Depth vtCCJ� <br /> Depth I Filler Material i Depth Air <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i Mo septic system permitted if public sewer i <br /> available within 200 feat.) <br /> Installation will serve: Rest ce Commercial_ Other ' <br /> Number of living units: 'er of bedrooms <br /> Character of soil to a depth of 3 feet: # stet table dep h <br /> SEPTIC TANK. ❑ Type/Mfgf Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance tnearest: Well];�:�undatpon Property Line <br /> LEACHING LINE Cl No. & Length of Ii al length/size <br /> FILTER BED ❑ Distance t eras[: Well Foundation rty line <br /> SEEPAGE PITSDepth Size Number <br />�im �SUMPS-­—= istanee-to-nearest:: Well.= - —_Foundation�.---z-.-- Property-Litre: <br /> DISPOSAL PONDS ❑ <br /> I hereby canify that 1 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 workmen's compensation laws of California." Contractor's hiring of 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 must call f r all r uired inspections. Complete drawing//on reverse side. <br /> Signed Title:Ir `niL�l ?�i _ Date: <br /> FOR DEPARTfNENUSE NLYj! t.s <br /> I Application Accepted by NJ Date a,710,3_ Area 2/ <br /> Pit or Grout Inspection by {sate Final Inspection by Date <br /> ma� <br /> Additional Communis: _Q2 ��c� <br /> r i7,--� 2—�Z <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 /> INFO [AMOUNT DUE AMOUNT.REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> i . EM 14.26(REV.;,w s1 T4 T s t "F 4Ls0 Cp f z '3L� Ict3� 1 <br /> EH t�•ZE <br />