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APPLICATION <br /> SAN 30AQUIN COUNTY PLIC <br /> BHEALTH <br /> SERVICES <br /> ENVIRONMENTAL H <br /> ON <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork 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. <br /> z� - I L. kA. City Ami Lot Size/Acreage <br /> Job Address <br /> Owner's Nam <br /> .91LIb,) cw Address CIA Phone <br /> Ar'I t9>prA(A;nr� License No.C �f>Sr 4� Phone D X13 -SBC <br /> Contractor r� Address <br /> TYPE OF WNEW WELL ❑ WELL REPLACEMENT h DESTRUCTION Li Out of Service Well C]OTHER Monitoring Well <br /> ELL/PUMP: <br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ Sy,►86-10$ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION .r <br /> L7 Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation D Dia. of Well Casing <br /> Cl Domestic/Private )(Gravel Pack L3 � y <br /> Tracy Type of Casing_ 5 • L0 fd` Specifications <br /> r CCY ALvt <br /> I'1 Public fa Other n Delta Depth of Grout Seal �' � Type at Grout <br /> I I Irrigation <br /> Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done , � A � <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted it pu lic sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial — Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Welt Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED I I Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> t.. <br /> I hereby ceitify that I have prepared"this pa p lzation and that the work_will be one in accordance—w1tFi San Joaquin county ordinances, state laws, 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 performance of the work for which this permit is issued, I aheh not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif 10A�� <br /> 11 <br /> The applicant d inspections. Complete drawing on reverse side. <br /> Signed Title: . RAC 6tt-44Kr, f- Date: <br /> bFOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by ' Final Inspection by Date <br /> Additional Comments: <br /> Applicant -- Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMIT-TED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> . EH 13-24IREV.1/A 51 <br /> EH 14.28 <br />