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APPLICATION SR # L <br /> SAN JOAQUIN COUNTY PUBLIC HEAD VICES ��/ <br /> ENVIRONMENTAL HEALTH DI4i& <br /> �� -6 7 <br /> 445 N SAN JOAQUIN, PHONE (2 �� <br /> \� P 0 BOX 2009, STOCKTON, <br /> T <br /> (Complete in Triplicate) —"— <br /> Application is hereby made,to Baa Joaquin County for a permit to coaatruct and/or install the work herein Described. This <br /> application is sada in compliance with Baa Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Putlie Health services. �+ <br /> Job Address �r 1�, Sf"�c�r1 Q.tr` City 6j Cyi/1 Lot size/Acreage `! <br /> Owner's Nems ��4�� Ra+ Address ��3 + S�''1 Vfft n rC 0 Phone �3 -7 <br /> — �( <br /> MM}} 1� /y _. <br /> Contractor �• H� (r4ttM^ Address r'a i Casa Licefise <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT IFY,' DESTRUCTION O out of Service Vell Gl <br /> PUMP INSTALLATION 0 SYSTEM REPAIR a OTHER O Noaitoring Stell Q <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP, UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL��PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial 0 Open Bottom Ci Manteca Dia. of Well Excavation_ Dia.of Well Casing <br /> r.l [ownesticiptivate 0 Gravel Pack ❑ Tracy Type of Casing Spacifiaaetons <br /> I'1 Rublic Cl Other 1-1 Delta Depth of Grout Sea! Type of Grout <br /> I i hlr4stton Approx. Depth I I Eastern Surface Ssdi installed by <br /> Repair Work DOM L3 Type of Pump H.P. Stats Work Dons <br /> Well Destruction Q WON Diameter Sealing lbt:erial i Depth <br /> Depth biller Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIRlADDtTION ESTRUCTION 1 I INo naptic system permitted if public sewer is <br /> I,/' available within 200 fest.) <br /> Irotailation will serve: Residence— CommarcW T other <br /> . N{rnbsr of living units:_ 11 Number of bedrooms <br /> Character of soil to a depth of 3 feet:_ .S-ndY bur,o( s Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Congwnrvwm <br /> PKG.TREATMENT PLT,O Method of Disposal <br /> awance to nssrost- Welt Foundation T Praparty Lies <br /> LEACHING UNE No. 6 Length of lines a Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation Property Une <br /> SEEPAGE;;PITS H'Depth Number <br /> SU PS LI Distance to nenrest: Well Foundation Property Line <br /> DfS1tL PONDS O <br /> I hereby cattily that I have prepared this application and that the work will be done in accordance with San Joaquin county ord neneas,chafe Iswa,and <br /> rules and rogulslions of the San Joaqun County <br /> Homs owner or licensed agaWs sipnatura conifiies the folkowing: "I ceftify that in the performance of the work for which this permit is issued, I sMi r4i <br /> MOW any person in such manna►as to became subject to workmsn's compensation taws of California."Contractor's hiring or vubreontracting aig wWra <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued.I sha8 employ perm-ts subject w workntart's cornparrsa- <br /> tion laws of Cmillornle." <br /> The applicant nwstS d for r%l required inspractions. Complete drawing reverse side. <br /> Signed x--.I� 7 Title• �w A-eA" Date• <br /> FOR DEPANiTMEftET USE ONLY <br /> Application Acc4r�teq by Date <br /> L Pt!or Grout-frtepectlon by Date_�_ Final Inspection <br /> Addltlonal-,Commente. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N man Joaquin, P O Boa 3009,, Stkn, CA 8520 <br /> FEE J/ WFFO AMOUNT DUE AMOUNT REMtTYEO CASH RECErvED Y ,/DATE PERMIT,/No. <br />