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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN -JOAQUIN, PHONE (209)468-- <br /> P O BOX 2009, STOCKTON, CA 952 �p <br /> PERMIT ESPIRES 1 YEAR FROM DATE ISS", <br /> (Complete in Triplicate) NN CC������Jjj <br /> Application in hereby made to San Joaquin County Por a permit to construct and/or in fo N � #1Aicrib.d. This <br /> application is made in compliance 'with San Joaquin County Ordinance No. 51+4 and 1862 an 'dations of San <br /> Joaquin County Public Health Services. y <br /> Job Address City Lot Size/Acreage <br /> I <br /> Owner's Name Address <br /> o T✓-AP;k&JI �D�G- k_IfC�Jh — Phone -- 33 3 <br /> Contractor Address ►!d i�+1 ,�t�i1� License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> H�,o Q.i PUMP INSTALLATION ❑ SYSTEM REP NA ❑ CITHED be Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL PLD. PROP. LINE Ls�T"f <br /> FOUNDATION ;.AGRICULTURE WELL THER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F1 Industrial ❑ Open Bottom Cl Manteca Die. of Well Excavation Dia. of Well Casing — ~� <br /> Domestic/Private ❑ Gravet Pack 0 Tracy Type of Casing_ Specifications <br /> V1 Public KqIher (Delta Depth of Grout Seal --- Type of Grout <br /> I I Ir(ivation 3 7 Approx, Deptti I 1 Eastern Surface Seal Installed by —^—� � l <br /> Repair Work Done ❑ Type of Pump _ H.P, State Work Pons <br /> Well Destruction A Well Diameter S me% &� Sealing Material Depth <br /> Depth ._- '3e'! -Ff _ Filler Material a Depth r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I ' REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_..` Commercial Other <br /> Number of living units: Number of bedroom <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compenments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines A Total length/size <br /> FILTER BED 1=1 Distance to nearest: N4±_ <br /> Foundation Property Line <br /> SEEPAGE PITS 11 Depth re Number <br /> SUMPS L1 Distance to nearest: ell Foundation Property Line <br /> DISPOSAL PONDS ❑ <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, an <br /> rules and regulations of the San Joaquin County <br /> Home owner or litensed 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 or sub-contracting signat= ``--'' <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 for all requ' ed ins ctions. Complete drawing on reverse side. C <br /> Signed X Title: Date: --L 3 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data —Z 1 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date ^ 3 <br /> Additional Comments: <br /> Applicant - Return all coplee to: San Joaquin County Public Health Services a�sD �� <br /> Environmental Health Perm .r <br /> it/Sevicert <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 <br /> CASH RECEIVED BY DATE PERMIT N0. <br /> Eet32<IREV.k,H5)s$ 71 DO �� l�t 1 p� <br /> EH 14.2e `\ • 4 —21 ``{ 3�D 169 <br />