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In <br /> APPLICATION <br /> SAID JOAQUIN COUNTY PUBLIC HEALTH,SES" <br /> ENVIRONMENTAL HEALTH DIVISON <br /> 445 N SAN JOAQUIN,PHONE(209)46 440 # "j a <br /> P O BOX 388,STOCKTON,CA 95201 0 ( IL' <br /> 2 PERMIT EXPIRES 1 YEAR FROM D3'T'SS <br /> (Complete in Triplica e) . qg <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.This application rs ma e m_com—pTua—Me WithS�tta <br /> Joaquin County Development Title Section 9-1110.3 and ection 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br /> Job Address G' { Cj - City �46­1-�t Size/Acreage <br /> I , <br /> Owner's Name z F�m/6�>•1%o Address Phone c <br /> t <br /> �r t�!1 Address �` r ry <br /> ContraUor C License No., - � � 7 _F'hon <br /> TYPE OF WELL/PUMP: -NEW WELLyY� WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR L7 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 21=/ SEWER LINES _e75C» f DISPOSAL FLD. PROP. LINED_" <br /> FOUNDATION 1�26 AGRICULTURE WELLAL-9—OTHER WELL „ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom 0 Manteca Oia. of Wall Excavation Dia. of Well Casing 055f <br /> Z . mestic/PrivatB Gravel Pack ❑ Tracy Type of Casing_ %L_ Specifications <br /> ('I Public Cl Other ,/ ❑ Delta Depth of Grout Seal �/_ Type of Grout <br /> I 1 Irrigation �Approxfo&pth I I Eastern Surface Seal Installed by/_1:Lef 7 <br /> Repair Work Done L3 Type of Pump H.P. _ State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing )Material 4 Depth Q <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADOITiON I I DESTRUCTION I l INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Instal)ation will serve: Residence— Commercial— Orl,et PAYMENT <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: RJE C E V E water table depth <br />!SEPTIC TANK 0 Type/Mfg CapacittanV �Qj!�+lo. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> AN JOAQUiN <br /> of Disposal <br /> OUPf.M'ad <br /> Distance to nearest: Well Founda �� Y(" <br /> ENVIROWENTAL H AI TH n1wlWN- y <br /> LEACHING LINE Cl No. & Length of lines Total length/size I +1 <br /> FILTER BED n Distance to nearest. Well Founoatron Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate 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 taws 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, I shell employ persons subject to workman's compensa- <br /> tion laws of California." <br /> I <br /> iThe applicant trust call for all required inspections. Complete drawing on reverse side <br /> Signed Title: .L P+� -- Date: iti j <br /> j FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date v hd Area <br /> Pit orout I spection by / Data Final Inspection by Date �?��L <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> I ^� Environmental Health Permit/Services <br /> t 445 H.San Joaquin,P.O.Sox 388,Stockton,CA 95201-0388 <br /> m <br /> a <br /> INFE AMOVNT DUE AMOUNT REMITTED � R RECEIVED BY DATE PERMIT <br />