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t APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> l ENVIRONMENTAL HEALTH DIVISION <br /> Lel/EZE <br /> 445 N SAN JOAQUIN,PHONE(209)469-3420 <br /> 1S{k'rc� P 0 BOX 388, STOCKTON, CA 95201-0388 r ^ -33 3 Allo <br /> PERMIT =IRES 1 YEAR FROM DATE ISSUED <br /> (Complete ;in Triplicate) , 1 001 —Z30—Z1 <br /> t .�P[ ill• r�1,C' tfQ=O . t <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.This application is made in compliance with San <br /> Joaquin County Development Tid n 9.1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public ealth Services. <br /> Job Address / �IS 3i/8 City __ Lot Size/Acreage <br /> /O i Phone <br /> O er't Name Address' ' <br /> Contractor � �S S Addres i,5y `r' �RGC�/� cense No. �o7L none <br /> TYPE OF WELL/PUMP NEW WELL C WELL REPLACEMENT DESTRUCTION tl Out of Service Wei i ❑ <br /> PUMP INSTALLAT}ON'G SYSTEM REPAIR ❑ - OTHER ❑ Monitoring Well (3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS rl <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial O Open Bottom ❑ Manteca Dia of Well Excavation Dia. of Well Casing <br /> [l Domestic/Private ' O Gravel Pack ❑ Tracy Type of Casing_, Specifications <br /> Il Public ^,.� ('I Other r Delia—'I } Depth of Grout Seal Type of Grout <br /> irrigationf Approx. Depth l I Eastern Surface Soul Installed by <br /> Repair Work Done L7. Type of Pump H.P. ___� State Work Done <br /> Well Destruction Clf Wel! Diameter LIit Sealing Material i DepthI / / <br /> Depth r a Iiller Material i Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I R AIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 lest.) <br /> Installation will serve: Residence Commercial — Other <br /> I ' - Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> '.SEPTIC TANK [3Type/Mfg <br /> Capacity � No. Compartments" <br /> PKG. TREATMENT PLT. ❑ Method of pittposa�lp� <br /> Distance to nearest: 1 Well Foundation Property Line�1�H Ct�IECYI A <br /> LEACHING LINE D No. S Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property line SAN JOA WN COUNTY <br /> tbPI.IBLIC HEALI'Ea SERVICF <br /> l` SEEPAGE PITS i I Depth Size Number L ry, NV 7A <br /> -j�Ai_7H pkV15101 <br /> f SUMPS LI -Distance to nearest: Well Foundation Property Line <br /> ffff DISPOSAL PONDS ❑ <br /> f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, 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 laws <br /> California."ce the work for which this permit o issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of CrContractor's hiring Or sub contracting signature <br /> Cori the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons sublecr to workman's eompense <br /> i tion laws of California." - ` <br /> The applicant t;,All for all r %ed inspections. Complete drawing on rsvetss side. <br /> us '� 9 <br /> ed x_ <br /> tle: Date: <br /> SignTi <br /> ([ FOR DEPARTMENT USE ONLY <br /> ' Date Area <br /> Application Accepted by I _ <br /> Date <br /> ' Pit or Grout Impaction by Date _ Final inspection by <br /> i Additional Comments: _ <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> t Environmental Health O.Bo388S Permit/Services <br /> N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 <br /> i <br /> FFEE �I �L <br /> 2-iA- <br /> MITTED K RECEIVED liY DATE PERMIT N0��� SH <br /> (h1) ����- f( —E is- 17/o <br />