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,APPLICATION FOR PI <br /> SAN JOAQUIN COUNTY PUBLIC HTsAL <br /> ENVIRONUMAL HEALTH DIV SIML <br /> 445 N SAN JOAQUIN, PHONE (20 <br /> P 0 BO% 2009, STOCKTON, C <br /> RMWIT EXPIRES I XM EROM D <br /> (Complete in Triplica e <br /> Application is hereby asde,to Ban Joaquin County for a permit to construct and/or iso <br /> appltcation.is ►cede to caWliance with San Joaquin County ordinance No. 549 and 1562 and the Rules and Regu.7,aticns of Ban <br /> Joaquin County Public Health Servi, es. <br /> Job Address City dN t Lot SiselAcraiu, <br /> c,.l ' �_ _. _ r <br /> Owner's Nrrrta�1,(�f'd�•r�'.�Gl Vis" i �.L: L['. Address ��r' � �}� Lt rl s1`!I Phone <br /> _ r w' _ t2 � ��� JContractAdQress __ + &G % Phone " 47b .5 rt'• <br /> TYPE OF WEL'LMUMP_ NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service well, ❑ <br /> PUMP INSTALLATION p• SYSTEM REPAIR ❑ OTHER 0 Monitoring well D <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. 4 PROP. LINE <br /> j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PAYMENT <br /> 0 Industrial ❑ Open Bottom C Manteca Dia, of Well Excavation <br /> Cl Dornealic/Private 0 Gravel Pack 0 Tracy Type of Casing $pqt: t <br /> FI Public 1:1 Other n Delta Depth of Grout Seal YIPL+7 4 41 150 <br /> 1 1 Inivalion —Approx. Depth I I Eastern Surface Seal Instatied by (iLIC FiI;AI TFi$£RV1r $ <br /> Repair Work Done L7 Type of Pump H.P. Stats Work MInUIVIVILN IAL 1­1LAL rH bivisi4P4 <br /> Wall Destruction 0 Wee Diameter Seeling Material i Depth <br /> Depth Filler Iaat:erial t Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I l DESTRUCTION I I IND septic system permitted it public sewer is <br /> 2W feet.l <br /> // a�ra'asbte rein <br /> Installackm will serve Rssidertce_ Commercial u Other ^�` .1 f!!_7 <br /> � `e. <br /> Number of liivirtq units: Number of s <br /> Character of soil to a depth of 3 fen: t`r"c-s� �— Water tabus depth <br /> SEPTIC TANK * Typ./Mfg4 Capacity t No. Compartments <br /> PKG.TREATMENT PLT.❑ / / Method of D I <br /> Distance to nearest. Web-/I/"'IC` Foundation '2!2j� Property Lina C- \ <br /> LEACHING UNE No.& Length of Was Total langthlsi:e llq(; X <br /> FILTER BED 0 Distance to neamt. Well _lt'e? Foundation. ./:0 Property Line f <br /> SEEPAGE PITS Depth J Sire lumber <br /> SUMPS LI Distance to naw*".. Wail f Foundation Property Line S >< <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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 /> Horne owner or lieenssd span's signrnus oanifies the following; "I certify that in the performance+of the work for which this permit is issued, 1 shall not <br /> employ any parson in such rnannor rya to became subject to workman's compensation laws of California."Contreetode 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 shall employ perosis subject to workman's compensa- <br /> tion lays of CalHomis." <br /> The applicant:must N for ag Fred inspections. Complete drawing on reverse side. J [/ <br /> 5igrtsd L -� .._�, .`c-'"t c Title: —-— � ! <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by CC; Date 7. f%fArse <br /> film Grout Inripactlon by BIG. i-sInspection by� 7 T <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin CountV Public Health Services <br /> 4VirOitl Health Permit/Services <br /> 41t <br /> 445 San <br /> JoJoaquin, P D Box 2009, BLkn, t3A 962 <br /> •/ <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED CK RECEIVED SY DA <br /> . iM l37r IREV. reel - '! // '!✓lJ6 <br /> EN U JJ <br />