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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL 14EALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE(209)469-3420 <br /> P 0 BOX 388,STOCKTON, CA 95201-0388 <br /> -PERMIT 9MIREg 1 YEAR ROM DATE ISSPED <br /> (Complete In Triplicate) <br />' Application is hereby made to San Joaquin County for a permit to construct and/)r install the work herein described This application Is made in compliance with San <br /> Joaquin County Development 7 ale Section 9-11110 3 and Section 9-I 115 3 and the Rules and Regulations of San Joaquin County Public Health Services <br /> Job Address -�7 /JLS� =_! L/{ City C -� Lot bite/Acreage <br />' 1 f�,, / G_• --- -- - 95 aa7 <br /> Owner a Name S�C VC. ``'�ti`` �' r �r Address �jrJ S_�i� Imo { Phone <br /> Contractor Address _�( License No Phone 'd <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Ci Out of Service Well [1 <br /> PUMP INSTALLATION C, SYSTEM REPAIR ❑ OTHER 0 Monitoring Wellj �r <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES 3c'y -Al _ DiSPOO+tL FLO PYA PROP LINE r,.v47 <br />' FOUNDATION ----L2-- +--AGRICULTURE WELL Lt- OTHER WELL---f, _ PITS/SUMPS &A <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS if <br /> Cl Industrial O Open Bottom ❑ Manteca Du of Wali Excavation Dia of Well Casing <br />' Iii Domestic/Private ❑ Gravel Pack C; Tracy Type of Casing__ Specrficatrons�._, <br /> I I PublK I I Other f ��� <br /> l Delta Depth of Grout Seal ZY'7" pGsl�u+s, f Type of Grout (' ~ <br /> I I ImUmion Appros Depth t I Eastern Surface Soul installed by <br />' Repair Work Done U Type of Pump H P -- Slate Work D a <br /> Wolf 0e21fuction ❑ Wail Diameter I Se&ling Material i Depth ery r+4t- 3- <br /> Depth _' Piller Material i Depth 12 , <br /> TYPE OF SEPTIC WORK NEW INSTALLATION ' I REPAIR/ADOITION I I DESTRUCTION I I (No soprtc system permitted if public rower it <br /> ID <br /> available rvithrn 20D feet f <br /> Installation will serve Residence _ Commercial_ Other <br /> Number of living units Number of bedroomt <br />' Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK D Type/Mfg Capacity` No Contpartmantt <br /> PKG TREATMENT PLT 0 Method of Oifipose <br /> Distance to nearest Well Foundation Property Line <br /> LEACHING LINE 0 No 8 Length of lines _ _ Total length/stat <br /> FILTER BED n Distance to nearest Wall Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sirs Number <br /> SUMPS Ll Distance to nearest Well Foundation Property Line <br />' DISPOSAL PONDS O <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances slits laws end <br /> rules and regulations of the San Joaquin county <br /> Home owner or licensed agent s ugnstura certrhas the following I certify that in the owformancs of the work for which this permit is issued I shall not <br />' employ any person m such manna, as to become subleet to workman s compensation laws of California Contractors hiring or tub-contracting signature <br /> certifies the following I certify that in the performance of the work far which this permit is issued I shall s►-ipfoy persons subject to workman/companaa <br /> Tion laws of California ' <br /> The ■ppltcan must call f"t r?quoted inspections Complete drawing on reverse side �+ <br /> Signed x�-%- -J��L Title r F Date- 1�I~!y <br /> FOA DEPARTMENT USE ONLY / <br /> Apphcauon Accepted by Data Area <br />' Pit or Grout inspection by Date Final Inspection by Data <br /> ditlonal Comments <br /> Appli,ant - Return Ril copies to San Joaquin County Public Health Services <br /> Eni,iroarnental Health Penritt/Services <br /> 445 N San Joaquin,P 0 Box 388,Stockton,CA 95201 0388 - <br /> NFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT NO <br />