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10 APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEATTH SERVICES�� Lg�� <br /> ENVIRONMENTAL HEALTH DIVISION �� <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 JON 2 g 1995 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDEWPONMENTALW <br /> (Complete in Triplicate) pEIZTJE <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or installthe herein described. This <br /> application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules work <br /> work and Regulations of Sm <br /> Joaquin County Health Seervices. c <br /> Job Address 1 p--S 1 I V 1�0+ � —V4 ,., <br /> \\ _ City tzU . 'E/�--1 Lot Size/Acreage <br /> Owner's Name`` A A)nt �1lT ©s ` Address •%x�("O( `©)(To,,ur (�32 Phon�� <br /> Contractor�?Q57 Address 3 icenseN0�_PhoneQt 39"72 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL—REPLACEMENT M DESTRUCTION OVOut of Service Well ❑ <br /> PUMP INSTALLATION ❑, SYg7TTEMM REPAIR ❑ OTHER Me monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK y� SEWER LINES DISPOSAL FLD. Y1 W PROp. LINOLS"' <br /> ' <br /> FOUNDATION '!.]� AGRICULTURE WELL Z—� OTHER WELL >15V PITS/SUMPS 7I <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 /> f'.1 Domestic/Private ❑ Gravel Pack L (racy Type of Casing_ Specifications <br /> I'I Public 1:1 Other f1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seel Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> 1r'/11,W-aN-0eso-w 1 ❑ W It Diameter Sealing Material & Depth <br /> 1 V. e; 1't K.tO� t -�'�— Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of wil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <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 /> 1 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 workmen'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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust ca for all quir inspections. Complete drawing on <br /> reverse sid <br /> e. <br /> V QOSigned Title: � IST <br /> Date: 61017,1 <br /> O9ITY - O� FOR DEPARTMENT USE ONLY �f.O� (,,l,• <br /> Application Accepted by lam, <br /> /w - Date 6 y7 S Area f�af/.rtieh � �'� <br /> � IzPit or Grout Inspection by Date Final Inspection by Date <br /> Additional Commenn: <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 /> LT <br /> NT DUE AMOUNT REMITTED Ck RECEIVED ay CASH DATE RERM17 NO.EN I7I�IREV.rrx510 �� °b. bg3ttj I�' N-�f �� �Q t" 00/yJ7? <br /> EN t4.ia <br />