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i <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC FI � <br /> \ / ENVIRONMENTAL IIEALTI D I ON <br /> 445 N SAN JOAQUIN, PHONE `6 <br /> P 0 BOX 2009, STOCKTON,_A� 5201. <br /> PERMIT RKPIRES 1 YEAR FROM DATE ISSUED_ <br /> (Complete in Triplicate) <br /> Application is hereby raae,to San Joaquin County for a permit to construct And/or install the vork herein described. This <br /> application is man in compliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> x r^_;7 C", I k f� �rG _ Lot SSzelAcre.ge <br /> Job Addross <br /> �a / J LAddrass L 124>' phone <br /> Owner's Namelv_Elo ) /� <br /> Contractor A x --- -Address '��° ��r, t.�—�License No._ _ Phone -- <br /> TYPE OF WELL/PUMP: NEW WELL r3 WELL REPLACEMENT i1 DESTRUCTION Cl Out of Service Well Q <br /> PUMP INSTALLATION n SYSTEM REPAIR C) OTHER G Monitoring Well n <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES —__—_ DISPOSAL FLO. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER V%ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Industrial O Open Bottom u Manteca Dia. of Wall Excavation.-- Dia. of Well Casing <br /> (7) Domestic/Private n Gravel Pack 11 Tracy Type of Casing__.__-___— Specifications <br /> Il Public I:)Other FI Delta Depth of Grout Seal Typo of Grout <br /> 1 1 itrivaoon Approx. Depth I I Eastern Surface Seal Installed by w <br /> Repair Work Done U Type of Pump H.P. _____..___..— State Work Done <br /> Well Destruction Cl Well Diameter __ Sealing Materlal i Depth <br /> Depth Filler Material Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDIN0N , DESTRUCTION I I (No septic system permitted if public sower is <br /> available within 200 feat.) <br /> Inslsllation will serve: Residence L� Commercial_ Other <br /> Number of living units: .____, Number of bedrooms I <br /> Character of &OH to a depth of 3 foal: __ Water table depth <br /> SEPTIC TANK O Type/Mfg __ ...� �� _ Capscity_ EQ-_41 No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: well iL Foundation�le L_ Property Line <br /> LEACHING LINE ,et' No. b Length of lines ..__ _ Total Iengthlsirs l IS tz <br /> FILTER BED C) Distance to nearest: Well r Founcatlon 1 L!T t_ Property Line <br /> SEEPAGE PITS Depth -a5J f Siro _ Number.. <br /> SUMPS orf' Distance to nearest: Wall =�hfitFovndation.lcln._ __ Property Line £ <br /> DISPOSAL PONDS Ll <br /> I hereby certlty that I have prepared this application end 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 ficensed agent's signature cenitiee the following: "I certify that in the performance of the work for which this permit is issued, I shalt not <br /> employ any person In such manna:as to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: '7 certify that in the performance of the work for which this permit is issued,I shall employ parsers subject to workmen's compensa- <br /> tion taws of California." <br /> Tho <br /> PP <br /> c t stcallfoallad C pe.cfions. Complete drawing on reverse side. <br /> Signe ��`fT G��' Title:_&4 Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application ccrpted by _.� Date '1 d Ep <br /> Area Z / <br /> Pit or Grout Inspection by _, Data __ Fine] Inspection by 44W Dais /,z <br /> Additional Comments: <br /> Applicant - Return all copies to: Ban Joaquin County Public Health Services <br /> Environmental Health permit/Services D l(Jbi-76-7 <br /> 445 N San Joaqui nos 2009, stkn, CA x95201 LJ <br /> INFO AMOUNT OUE AMOUNT REMITTED 1 C1K RE <br /> C <br /> EIVED BY '1OAT( PE/RMIT N0. <br /> EHtJrlfaEv.trnsr !II �- ri, 4 00` <br /> �S <br /> f H 11 2e <br />