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--� APPLICATION <br /> ` SAN JOAQU IN COUNTY PUBLIC HEALTH SERVICE C <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 9520 1l•�fr_ +� T" b65 — 12 1. <br /> PERMIT EXPIRES Y YEAR FROM DATE 5 <br /> (Complete in Triplicate) ft <br /> Application is hereby made to San Joaquin county for a permit to construct and/or irfetsi.]` <br /> work herein eseribe8. This <br /> Application is made in ccopliance vith San Joaquin County Ordinance No. 549 and 1862 and the RuZeti axe e <br /> Joaquin County Public Health Services. r <br /> 5 �(Lr�f/�Tc'-!L Y Lot Size <br /> } <br /> Job Address , Cit <br /> 11Lew*:+r'T <br /> � 4 G T-#F''TON <br /> Owner's Name C Address Sfi-rYt 12- -f1San �19 <br /> a contras tar cress �� �] l�ic�e se No_ J�Z Phoneys'' <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT { 1 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER nY ri <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. --PAAP-bWE- f <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G`l DJ <br /> n Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation 1 f <br /> F -) Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ -S,pa64ic� <br /> ! i'I Public 0 Other [-I Delta Depth of Grout Seal lype-a--Gmut <br /> I i Irrigation —Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work pone <br /> Well Destruction 0 Well Diameter Sealing Material i Depth ! <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK_ NEW INSTALLATION I 1 REPAIR/ADDiTJON I I DESTRUCTION I I (No septic system permitted if public sower is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> 4 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 TWaiM119 Capacity No. Compartments i <br /> { PKG. TREATMENT PLT. Ul Mel sal <br /> Distance ' <br /> to nearest: Well Foundation Property Lt� NT <br /> -- Rr�iVD----- <br /> LEACHING LINE Cl No. & Length of lines Total lenythfsiae <br /> FILTER BED 0 Distance to nearest: Well Foundation Pro�tty,Ljr�e� N COw I <br /> fifv JJ VV UNTY <br /> SEEPAGE PITS I 1 Depth Sire NumSN <br /> ICES <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina IbjO <br /> DISPOSAL PONDS 0 <br /> t hereby comity that t have prepared Ihis application and thal the work will be done in accordance with San Joaquin county ordinances. State laws, and <br /> rules end regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cerlifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any portion in such mannef as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> Certifies the following:"I sonify that in the performance of the work for which this permit if issued.I shall employ persons subject to workman's compensa- <br /> tion laws of Califorala." <br /> The applicant rest,call forl::F�gaited Inspections. Complete drawing on reverse side- <br /> Signed <br /> / <br /> Signed 1 Title: C'��7T f., , Date: 4-70 2 <br /> i <br /> FO DEP TMENT USE ONLY f i <br /> Application Accepted by t Date Area <br /> Pit or Grout Inspection by Gate `Final Inspection by Date <br /> Additional Comments; i <br /> Applicant Return all copies to: San Joaquin County Public Health Servie" <br /> Envixaam <br /> ental Health Permit/Saxvicea � 1{ <br /> 445 N San Joaquin. P 0 Box 2009, Stkn, CA 95 01. -t <br /> EAMOUNT DUE AMOUNT AEMITTEo CK RECEIVED By 4ATE AERryIiT N0. <br /> r EN 13-21[PIEV_I rA S 4 1. l q I f fyl?& <br /> EH U 10 Y L. t/ t , <br /> I <br />