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APPLICATION ����-�71 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 4145 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br />' PERMIT =IRES 1 YEAR FROM DATE ISSUED <br /> ! (Complete -in Triplicate) <br /> 4 <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> j application is made in compliance with Ban Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> f Joaquin County Public Health Services. } �r� ]� LBaZ' 3 - 10 <br /> ozgl S zJ�Q�9 , J /�i - City Lot Size/Acreage <br /> Job Address � O'- L.-eJ <br /> DAddress Phon�� <br /> Owner's Name XUi3o( 5_�g3 <br /> r <br /> 5� I C�5 J <br /> r <br /> 1 J Contra'clors5o/Lf> ZA2 =J ddress nae No � ne <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Nell ❑ <br /> -11 <br /> �� r�� lM REPAIR ❑ OTHER O <br /> SYSTEM Monitoring Well <br /> PUMP INSTALLATION ❑ <br /> 'I DISTANCE TO NEAREST: SEPTIC TANK _,r1.1I_ SEWER LINES f _ DISPOSAL FLD�. ��L��1 <br /> l�/�� PROP. LINEN <br /> t' <br /> FOUNDATION !-- AGRICULTURE WELL i ..., OTHER WELL---L20 PITS/SUMPS1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial <br /> El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f7 in <br /> C1 Ddustri clPrlvate Cl Gravel Pack ❑ Tracy Type of Casing �A �11A � ___ Specifications t <br /> I'I Public 1-1 Other f-1 Delta Depth of Grout Seal `v Type of Grout <br /> 1 I Irr+Uation •w+• Approx. Depth I I Eastern Surface Seal installed b,�x,� <br /> Repair Work Done U Type of Pump �! H.P. �� Sta a Work Pone _ <br /> ' <br /> Well Destruction ❑ Well Diameter sealing Material i Depot <br /> Depth_ 20 � Filler Material f, Depth ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> ' Installation will serve: Residence — Commercial^ Other <br /> " Number of living units: Number of bedrooms iV <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Properly Line <br /> t v <br /> N <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> I FILTER BED n Distance to nearest: Well Foundation Properly Line <br /> ` SEEPAGE PITS i I Depth Size Number - - <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I cerlify that in the performance of the work for which this permit is issued. I shall nc <br /> employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signatur <br /> certifies the following:"I certify that in the performance of he work for which this permit is issued,I shall employ persons subject to workman's compenam <br /> l tion laws of California." <br /> The applicant mus all for all to ulred inspeeti n . Complete drawing on fever e side. ` <br /> G <br /> Signed 1Ale Title. Date: <br /> Q� EPARTMENTW ON Y <br /> I <br /> Application Accepts by Date -d Area <br /> Pit or Grout Inspection by Date 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 /> 1445 N San Joaquin, P O Box 2009, Stkn, CA 95201 A110 <br /> a FEE <br /> INFO AMOUNT DUE AMOUNT�; `r R�E�[Mq r_TTED If <br /> CASH RECEIVED BY �^DATE PERMIT NO." <br /> . FN 11.71IrtEv.1/ 6r Y��� !J ✓t/ <br /> 2 <br />