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k <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN;'`PHONE (209)468-3420 <br /> fi P 0 BOX 2009, STOCKTON, CA 95201 <br /> �t F , ! <br /> PERHIT EXPIRES YEAR F OM DATE ISSUED <br /> -' (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. Q.�i p P <br /> �_ citVr!—� tOL S12e/Acreage,{ j L^ — <br /> Job Address '7 lG77 Lf y r r f <br /> :J / zj <br /> Address <br /> Owner's Naim <br /> m f e ` 1/1 - <br /> 1 �� f <br /> Phone <br /> .So4License No..*_ <br /> %.ontraclor: _--Ad]ressY <br /> TYPE OF WELL;PUMP. NEW WELL WELLREPLACEMENT Fl DESTRUCTION L5 Out of 5ervicq Xell ❑ <br /> OTHER ❑ Monitoril Well ❑ t <br /> PUMP INSTALLATION ii. SYSTEM REPAIR J <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK __ PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> l� Industrial ; ❑ Open Bottom Bottom 171Manteca Dia, of Well Excavation <br /> Type at casing_ Specifications <br /> F�1 Domestic/Private ❑ Gravel Pack <br /> El Tracy Type of Grout I' <br /> i'1 Public 1-1 Other 11 Delta Depth of Grout Seal y <br /> I IrrK)atan t Approtc Depth t I Eastern #2Surface 'Jed1.Installed by' <br /> H.P. <br /> '+ `-State Work Done F \l <br /> Repair Work Done U Type of Pump Sesling tiaterial&-,Depth ~ <br /> Well Destruction I ❑ Well Diameter Filler.lfat4friah&.Aepth <br /> Depth <br /> t TYPE Of SEPTIC WORK; NEW tNSTALLAT10N REPAIR/ADDtTiON I DESTRUCTION I I afyailablelc system w thin 200}�ttted it public server is%�' ". <br /> instaN�on will serve: Residence Commercial Other <br /> s Number.of living units: Number of bedrooms _ • "1 <br /> r• Water table depth—2 <br /> .` 6-Mracter of soil to a depth of 3 feet: <br /> -1'' Capacity f C No. Compartments f. <br /> SEPTIC-TANK � K Type/Mf g O <br /> � ,- � / �,� Method of Disposal '- <br /> "' PKG'TREATMENT PCT. 0 <br /> j! -=2:j ��_.'Property-L-ine_1_ <br /> ✓f Distanceao anearest: :—Wellb Foundation z <br /> I �LEACHINGLINE' � No. & Lenith of lines Total length/size <br /> .y <br /> FILTER BED ❑•t;Distance.to nearest: Well Foundation Property Line <br /> e ---Number <br /> SEEPAGE PITS ; X Depth ,.LSiie -u <br /> SUMPS LI Distance to nearestr�:,Weil, MC Foundation f p,C Proper -uns <br /> DISPOSAL PONDS ❑ w <br /> i hereby certify that 1 have prepared thii application and that the work will be done in accordance with San`oaquin�county ordinances, state 1aw�and <br /> rules and regulations of the San Joaquin County <br /> 1 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 /> } <br /> employ any person in such manner as to become subject to workmen's compensation7aws of California."Contractors hiring or sub,,contracting signature <br /> certifies the following:"I certify that'in the performance of the work for which this permit ieissu�all employ persons subject to workman's compensa- <br /> tion laws of California." <br /> n <br /> The applicant must call for all required in coons. Complete drawing on reveise side. 1 <br /> 'signs Title: Date: <br /> �'. <br /> FO DE 'SE ONLYf�' <br /> Date ` —afAraa <br /> Application Accepted by '� +�"r;✓ �` _ <br /> a Grout Inspection In <br /> Date� ��' -'Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all _copies to: San Joaquin County Public Health 9crvice ri <br /> if Environmental-Health.Permit/Service.ss ' <br /> t 445 N`San Joaquin, P O,Box 2009., Stkn, CA 95201 <br /> IEE - ,AMOUNT DUE AMOUNT REMITTED <br /> R CEIVED 8Y DATE PERMIT NO. <br /> INFO D <br /> . £N 13-24 IHEv.kin 6! r <br /> iEN 14 29 V <br />