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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HE t�F�jVICES a <br /> ENVIRONMENTAL HEALTH DI <br /> SR # <br /> li�tt ..- <br /> 445 N SAN JOAQUIN, PHONE (20p� 420 <br /> P O BOX 2009, STOCKTON, CA =4 <br /> PERMIT EXPIRES 1 YEAR FROM D4TE IAUEB---- <br /> (Complete in Triplicate-)- - <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application 1s 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 l 446 7 G Al Ag 4- bZZ/ViAF City srO CA;701✓ Lot Size/Acreage <br /> Owner's Name AXnU J n UJ t,H(AtK S Address S A M e ? Zl,i— Phone442 42 6-461 <br /> 4 svc5 E F2c tkcK_)T" <br /> Contractor ACCA2 Address License No. 'O'lV Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION [�T-' 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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 11Y4mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout 67 <br /> 1 1 Irrioation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump 5u tj H.P. 13 /? _—_ State Work Done N¢ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth T 46A l <br /> Depth Filler Material i Depth it (..Z4L), 7— <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other aj <br /> Number of living units: Number of bedrooms � � <br /> Character of soil to a depth of 3 feet: a pth <br /> SEPTIC TANK O Type/Mfg Capacity CkilUsC nts <br /> PKG. TREATMENT PLT. ❑ MAYMf he i 4MAposal ✓' <br /> Distance to nearest: Well Foundation o <br /> LEACHING LINE D No. & Length of lines �� � ME <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well 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, 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, 1 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 permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant st 70;� <br /> l for all required inspections. Complete drawing on r verse side. n\' ///��,, Q <br /> Signed X Title: d-� y SaZ4_3 Date: —O�/ 7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date h Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: pan Joaquin County Public Health Services <br /> U Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> AMOUNT DUE AMOUNT REMITTED EC IVSD By DATE PERMIT'NO. <br /> 01 <br /> . <br /> CA <br /> FEE <br /> 13.2 IREV.v x sl E � �_J <br /> EH 16$e , <br />