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APPLICATION q5 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVI yy�� ppb 7Jz3 <br /> 445 N SAN JOAQUIN, PHONE <br /> P O BOX 2009, STOC%TON, CA 1 54Qb <br /> PERMIT RE 1 YEAR R D T ff <br /> (Complete in Triplicate /�Q <br /> Application In hereby made,to San Joaquin County for a permit to construct and/o I j�e work berelaTC <br /> tAbed. This <br /> application 1e made in Compliance with San Joaquin County Ordinance No. 519 and ¢ <br /> Joaquin County Public Health Services. 14 <br /> Job Address �`17�,�t �,,.E,�+�� r P f//��\�C/ity Of +� Loi Size/Acreage <br /> Owner's Name.A E` 7 �/lE-��L�/ d. ddresa •`--'�vE /�� _ P//hor ��� �,2 <br /> Cantractor �� A-71 e--- Address ! License NatZ2 0 Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION O Out of Service Well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well D <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 /> O Industrial O Open Bottom O Manteca Dia. of Well Excavation_ Dia. of Walt Casing <br /> N Domestic/Private O Gravel Pack ❑ Tracy Type of Casing__ Specifications <br /> I'I Public ❑ Other it Delta Depth or Grout Seat Type of Grout <br /> I I Irrigation _Approx. Depth 1 I Eastern Surface Seat Installed by <br /> Repair Work Done O Type of Pump H.P. State Work Done_ <br /> Well Destruction O Welt Diameter Sealing Material a Depth <br /> Depth Filler Material 1 Depth 1S <br /> • TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWAODITION I I DESTRUCTION I I INo septic system permitted if public sewer is J <br /> available within 200 feat.) „S <br /> Installetlon sulk serve: R dance_X Commercial_ Other <br /> Number o1 kvi units: Number of rooms 7, / <br /> Character o1 soil to a <br /> dd& o(3 feet: Nc .a _ 9K W&ur table dept I 1 <br /> SEPTIC TANK Type/Mfg 4`YNJE''S Capacity /1102!), No. Compartments <br /> PKG. TREATMENT PLT.❑ / 1 Method of Disposal ArE c <br /> Distance to nearest: Well 1� t Foundation S <br /> Property Line ]� <br /> LEACHING LINE No. 6 Length of linea 1 ` <br /> n0 Total length/size_ o <br /> FILTER BED C., Distance to rwrest: Wall lyG�G Foundation1�l 'C Property Line <br /> SEEPAGE PITS I I Depth _Size Number <br /> SUMPS LI Distance to morsel: Well Foundation Property Line w <br /> DISPOSAL PONDS 0 lY <br /> I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Laws, and <br /> rules and roWlsoaria of the San Joaquin County <br /> Hone owner or licensed&pant's signature arrnfies he following: "i certify that in the performance of the work for which this permit is issued, I shag not <br /> employ any Per such i Mor as to become subject to workman's compensation laws of California."Contractors hiring ar sub-contracting signature <br /> mrlitiu ft t 'ng "1 cordfy�Er the Performance of the work for which this permit is issued, I shall employ persons subject to workmen's compenu- <br /> tion lawn o eIi/orrua" <br /> The appy t must I or�li uked ins tion . om a drawing on reverse side. <br /> It <br /> n <br /> Signed ? Title: Date: <br /> ^ ,� FOR DEPARTMENT US ONLY <br /> Application Accepted by \`"�1'i'\')S Date Ata& <br /> Rt or Grout inspection by Data <br /> � Final Inspection by <br /> Additional Contmanta: Cier.JOC <br /> • <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental uPermit/Beryl cea <br /> 945 N San Joaquinin,, P P O Baa 2009, Stkn, OA 9520 <br /> f�-Z Ir FEET AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO, <br /> INFQ <br /> EH 13-34 <br /> EN 14Acal 1eEV,i nasi 5 13ti l.. l���1 S <br />