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16 APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby mode-to San Joaquin county for a permit to construct and/or install 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 <br /> blic �Health Services. <br /> Job AddressUff"'t1r <br /> ctJJ City Lot Size/Acreage <br /> Owner's Name vnIntFor-d Address w <br /> K.. ... Phone Z [ <br /> Contracto K/ `t'f�Add/rr!s� v License kW__ M3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL = WELL REPLACEMENT L.I DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION C. 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 /> C7 Industrial ❑ Open Bottom C Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C7 Domestic/Private jj�`Gravel Pack 'Tracy Type of Casing_ P/&541 L Specificationai <br /> I'1 Public L7 Other f Delta Depth of Grout Seal j TV/pe of Grout <br /> I I Irrigation _Approx. Depth 1 1 Eastern Surface Seal Installed by �� CJr!l!>:✓ <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material L Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION � i REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted it public sewer is <br /> qtr available within 200 feet.) <br /> Installation will serve: Residence/`!1�9 Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of soil 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 ❑ No. & Length of lines Total length/size <br /> FILTER BED MIA <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS /V, LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PO DS ❑ <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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 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 m 1 11 re irad T gcti Complete drawing on T reverse side. <br /> Signed Title: / /ea7y C7 ryL(JC,S r Date: 2r _ <br /> G Te'Gi e'S INC, <br /> �i <br /> FOR DEPARTMENT USE ONLY p o <br /> Application Accepted by 3i;iz= Date ` / Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <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 /> 3� /IN�yF�E AMOUNT DUE AMOUNT <br /> REMITTED /C H /REECEIVED BY OATE /PEERMIITT'NO. <br /> . EN 1124(REV.1 51 tlVr" 1U 7 S ! �17 <br /> EH 14-2e <br />