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s <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES {# <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-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 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. <br /> ` f a9 <br /> I�� Ai 1 1__ �) {� lot Size/Acreage - <br /> (J {E {-i17 �P City <br /> wJob Address q -7 { <br /> Name Address <br /> 1� i I- ' 0K P, Phone 1 2 <br /> x P License No.19 1 ." -.Phone <br /> Contractor v Q Address <br /> L � WELL REPLACEMENT (-1. DESTRUCTION ❑ Out of Service Well ❑ <br /> TYPE OF WELL/PUMP::.,, NEW WEL <br /> P-INSTALLATION C] SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring'W11 <br /> PUM <br /> DISTANCE TO NEAREST: SEPTIC TANK` SEWER LINES DISPOSAL FLD.1j - - PROP. LINE <br /> FOUNDATION ��AGRICULTURE WELL OTHER WELL._._,- PITS/SUMPS ARID <br /> INTENDED USE TYPE OF WELL PROBLEM AREA- CONSTRUCTION SPECIFICAT�S Dia. of Well Casing Q <br /> f7 Industrial pen Bottom ❑ Manteca Ria o#;Well Excavation�� i Q <br /> . Type of Casing_ Specifications <br /> 111 omestic/Private ❑ Gravel Pack ❑ Tracy q__ <br /> f I'1 Public I:1 Other cot Cl Delta Depth of Grout Seal Type of Grout <br /> �. <br /> l I Irrigation Approx, Depth I I Eastern Surface Saal Installed by, t <br /> Repair Work Done U Type of,Pump H.P. Ste a Work Done <br /> Sealing Material Dee <br /> Well Destruction ❑ Well Diameter �,. <br /> Depth= ' Filler Material b pth <br /> JIt TYPE OF SEPTIC WORK: -N6W INSTALLATION I ] REPAIR/ADDITION I ! DESTRUCTION I I availableerm <br /> 1w thin 2010 septc system 0 lost`led if public sewer is <br /> .dam <br /> In allatian will serve: Residence_� ,,,T Commercial Other <br /> _ <br /> Wumber of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. © Type/Mfg city No. Compartments <br /> + PKG. TREATMENT PLT. ❑ tf;� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I Total length/size <br /> LEACHING LINE CI..".No. Lengt4ne <br /> FILTER BED ❑ . Distance to Well Foundation Property Line <br /> t "'"" _"'_ Size Number <br /> SEEPAGE PITS 11' Depth <br /> SUMPS Ll Dista a to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS <br /> 1 hereby certify that I have prep red this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> f rules and regulations of the San Joaquin county <br /> Home owner or licensed agent's signature certifies the following: 11 certify 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 follo ing: "I certify that in the performance of a work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion <br /> r laws of Ca or <br /> 1 The appfican call for all requir ins ns. Complete drawing on reverse s'de. <br /> Signed X <br /> Title: C/D _ Date: <br /> OR DEPARTMENT USE ONLY <br /> I <br /> Data �" Area <br /> Application Accepted by <br /> kPit or®routepection by at . � Final Insfection by Date <br /> Additional'Commenis:_..- <br /> i. Applicant - Return a copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> f 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> E <br /> FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY BATE PERMIT'No. <br /> INFO <br /> -WN 67.00 S1• <br /> � EH 17-211REV.i/Hsr , <br /> EH 14.2E <br />