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APPLICATION <br /> SAN4QUIN COUNTY PUBLIC HEALTHRVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCSTON, I'CA 95201 <br /> PERMIT V IRES 1 YEAR FROM !DATES ISSUED <br /> (Complete in Triplicate)' <br /> I t <br /> Application is hereby made.to Sam Joaquin County for a permit to construct:And/or;linstall the work herein described. This <br /> application is made 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 ` Cit Lot Size/Acreage Q <br /> : <br /> Owner's Name :%Adk I7.r.`p�r^. Address , t; Phone <br /> T .e, .. <br /> Contractor1� ddress,,?,?dY/ rlssr� ri We No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 7} DESTRI=ON ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ are.�til <br /> DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i ['t K ;� &OUNDAT*N AGRICULTURE WELL OTHER W;vELt PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ci Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> i R Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- ;L Specifications <br /> I'I Public C] Other fl Delta Depth of Grout Seat if Type of Grout <br /> 1 I Irrigation _Approx. Depth I I Eastern Surface Seal Instafled'by <br /> Repair Work Done U Type of Pump H.P; �'`State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth Ji + <br /> Depth Filler Material 4 Depth 1} <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITfON I I DESTRUCTION f I INo septic system permitted if public sewer is <br /> ?P available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> r <br /> SEPTIC TANK ❑ Type/Mfg Capacity f No. Compartments # <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Lina <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> -FILTER BED ❑ Distance to nearest: Well FoundationProperty Line <br /> I� <br /> i' SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation i! 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, 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 I <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 /> t <br /> The applicant us a r I r uire i tions. Complete drawing on reverse aide. <br /> I'g <br /> Signed Title: Date: 7' �1,L <br /> DEPARTMENT USE ONLY! <br /> I <br /> Application Accepted by f AData Area <br /> it <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> as <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, S'tkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNTREMITTED CASH RECEIVED BY h DATE PERMIT'NO. n �ny� <br /> . Eli 13-24 1AEV.i i�51 I' �t I 1 fi <br />