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APPLICATI(,# <br /> r.� <br /> SAN JOAQUIN COUNTY PUBL;k� HEALTH SERVICES f <br /> ENVIRONMENTAL' HEA'GTH DIVISION <br /> ` 445 N SAN_JQAQUIN,' PHQNE (209)468-3420 <br /> P O BOX 2009, T <br /> STOCK CA 95201- F <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County fors permit to construct and/or install the worts herein described. This <br /> f application is made in compliance with San Joaquin county Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> II Joaquin County Public Health Services. <br /> t ` r <br /> Job Address e Y+T City 196rAA2AZ Lot Size/Acreage daX>7 <br /> Owner's Name . /G <br /> Address. �d WLQ <br /> <� Phone <br /> ip <br /> Contractor Address A), License No <br /> Phone <br /> TYPE OF WELL/PUMP; tNEW WELL ❑ WELL REPLACEMENT [1 <br /> + DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER' ❑ 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 <br /> L-] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 17 Domestic/Private ❑ Gravel Pack El Tracy Type of Casing_ Specifications <br /> I•I Public CZ Other 4 n Delta Depth of Grout Seat Type of Grout <br /> i I Irrigation Approx..,Depth ,,.I.1 Eastern _ Surface_Seul Jnstalled by <br /> Repair Work Done '0 Type of Pump H,A. State Work Done, <br /> Well Destruction O Well Diameter Sealing Material & Depth N <br /> Depths Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION , DESTRUCTION (No septic system permitted if public sewer is <br /> ¢£ available within 200 feet.l <br /> Installation will serve: Residence Commercial_ Other <br /> Number of livingunits; ` <br /> � Number of bedrooms <br /> Character of soil to a depth of 3 feet'� LL <br /> SEPTIC TANK —Water table depth <br /> Type/Mfg.�4�C11p �` 7�'�` ..� DapacitY No. Compartments o� <br /> PKG. TREATMENT PLT. ❑ x <br /> Method of Dirosal <br /> Distance.to nearest: Well Foundation _ J04. Property Line <br /> } .G <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation <br /> ,t Property Lina <br /> SEEPAGE PITS 11 E Depth � SireA Number <br /> SUMPS Distance to nearest: Wel <br /> ation Property Line- <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be <br /> done An accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County o <br /> Home owner or licensed agent's signature certifies the following: "I certify-that in the perform&e of-1Ae work for which this permit is issued, I shall not j <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 ehali':employ persons subject to workman's compensa- <br /> tion taws of California." � <br /> The applicant must call for all required inspection . Complete drawing on reverse side. <br /> Signed <br /> Title: �. <br /> a T Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ / I <br /> 0 m Date!. 4_ Area Z <br /> t Inspection by Date�?Final Inspection by�� <br /> Date <br /> Additional Comments: <br /> Applicant - Return all copies.to: San Joaquin County Public Health Services <br /> I Environmental Health'Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> IS <br /> ZEA7NT DUE AMOUNT REMITTED CK <br /> // CASH RECEIVED By DATE PERMIT'N0. <br /> EN 13.24{flEY.i/H5YJ� / �nA <br />