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APPLICATION. _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> • ENVIRONMENTAL HEALTH DIVISION PVA <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009; STOCKTON, CA 95201 <br /> jPERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> S (Complete in Triplicate) <br /> Application in hereby made to Sam'Joaquin County for a permit to construct and/or install. the work herein described. This <br /> epPlleatl0n is made in compllaneejvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> f; <br /> Job Address 7e 66 /Wye 11 4411 City Lot size/Acreage <br /> Owner's Name _,Ea�W®�dy //O�.O..a-fir .Address f &A46- /y°4l, 56641 Phone �- I <br /> ContractorA.q+ .t o.h.J Address ggj�� e!�� el!* Ayvel/ License Noo����l1.T Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O 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 /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation - Dia.of Well Casing <br /> n Oomestic/Private ❑ Gravel Pack: CI Tracy Type of Casing_ Specifications <br /> I'I Public f-? Other ',y Cl Delta Depth of Grout Seal Type of Grout <br /> I I litigation _Approx,'Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump ` H.P. State Work Done <br /> Welt Destruction ❑ Well Diameter Sealing Material & Depth t <br /> Depth Piller Material & Depth <br /> TYPE OF SEPTIC WORK; NEW• INSTAL -LATION REPAIRIADDITION 1 I DESTRUCTION I I (No septic system permitted if public sews,is available within 200 feet.) <br /> 'Installation will serve: Residence—11Commercial_ Other Me-I <br /> Number of living units: _L Number of bedrooms <br /> Character of sal to a depth of 3 feet:'I G/w v Water table <br /> . ❑ T depth <br /> SEPTIC TANKi <br /> Type/Mfg {ton cis�.s CapacitY �.ob o0 No. Compartments <br /> PKG.TREATMENT PLT.❑ 1 , Method of Disposal <br /> � 9� i <br /> Distance to.nearest: Wali��= Foundation Property Lina Or <br /> LEACHING LINE -No. & Length of lines �1G <br /> g _ <br /> �[ s�— + - Total length/size <br /> FILTER BED ❑ Distance to 3 <br /> mental: Well er Foundation Joy Property Line ,/./I? + <br /> SEEPAGE PITS 17( Depen —27 d'_1' Sirs `+ Number <br /> SUMPS LI Distance to nearest: W I cundation 26 r Property Line, -lQa, <br /> DISPOSAL PONDS O <br /> I hereby certify that 1 have prepared this application and that the work will be donein accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin.Ccunty <br /> Home owner or licensed agent's dgnature certifies the following: "I certify that in the performance of the work for which this per <br /> rtdt is issued, I shallniit y <br /> employ any person in such manmr as to become subject to workmen's compensation lava of California." Contractor's hiring or subcontracting signature ; <br /> eartifiea the following: "I unify 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 applicantcell fw all r ed inspecn0 s. Complete drawingon reverse side. <br /> Signed Title: 22 Dater <br /> ffOR DEPARTMENT.USE ONLY C s,�, <br /> ap Y � Date Area O� t 3�l'L� I <br /> &I "knud <br /> AAppplACC ted b / .S."A Cot; —Z. �� ,it Grout Inspection by b ✓tet Date ��45 Final Inspection by Oare Commit <br /> • Applicant - Return all copies to: San Joaquin County Public Health Services <br /> r <br /> Environmental <br /> Health Permit/Services <br /> SaJoaquin, <br /> 443 N San P P O Boz 2009, Stkn, CA 95201 <br /> FEE <br /> INFO// AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> EH13,24.25IeEV.I/AW ♦/ .A—D �/ .✓� 07.0`�6� �,. /(An ` n <br /> 7J��1 /Q <br />