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• APPLICATION • <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION / - <br /> , PHONE `(209)468-3420 <br /> OCBTON, CA - Few <br /> yS�,ty ` <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 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. E .� �• <br /> S1"RP6 oT}f (Lo D v4s-ro Z7- <br /> Job r.�nt2oP <br /> Job Address City Lot Size/Acreage <br /> Owner's Name AddresslCC�fT�C/F1J. CD� � Phone`r v����go <br /> Contractor GR.I 6r&- ijbtffi Address 1 Q90 HWW5M MAk'TIAJ67— C4 License No.qOp 516 Phones10°-313­98m <br /> TYPE OF WELL/PUMP. NEW WELL (2Mu)f WELL REPLACEMENT P�(Cy/ DESTRUCTION C Out of Service Well ❑ <br /> PUMP INSTALLATION C SYSTEM REPAIR ❑ (CPr) OTHER (Y Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ \ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r('EE�pCN6D jt, gK P"N)S1 <br /> C Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack C Tracy Type of Casing Specifications <br /> I'1 Public 1-.1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material L Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feat.) <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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ 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 /> 1 hereby certify that I hews prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home Owner or licansed agent's signature certifies the following: "I comity that in the performance of the work for which this permit is Issued, I shall 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 California." <br /> The applicant mu all for i r irad jaspe tions. Complete drawing on reverse side. <br /> Signed X Title: )1n;a xkLL r-• Date: a �/—f / <br /> v <br /> FOR DEPARTMENT USE ONLY �r p� � <br /> Application Accepted by �,�,� Date � AreaL. ✓��L�G� 6P"V <br /> Pit or Grout Inspection by Date <br /> Final inspection by Date <br /> Additional Comments: VP-) <br /> Applicant - Return all copies to: San Joaquin Court Public Health Services n <br /> Environmental Health Permit/Services �n'Q/. <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 7 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASN RECEIVED SV DATE PERMIT NO.EN 13-N(REV.v x v D� �� DO <br /> -t- <br /> ,` Page I3A <br /> EN,..m �l (JlL 7 �33o i <br />