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IL <br /> APPLICATION �r , 7 Y*-C <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH dAVICES� <br /> ENVIRONMENTAL HEALTH DIVISION ,- `a <br /> `f Q ` 445 N SAN JOAQUIN, PHONE,.(209)468-3420' <br /> ya <br /> P O 190X 2009 STOCgTON, CA 95201 _aa <br /> `�. PERMIT E%PIRES 1 YEAR FROM DATE I SiJID <br /> F <br /> (,Complete in Triplicate)-In <br /> work her* a <br /> Application ie hereby �e.to San Joaquin County <br /> J nt f F a to Ordinancomit to ngt�uct and/and 1862 sand thetalleRules and RegulationBesc dof Sans <br /> applieati'on Ss made in c®p q y <br /> ,Toaquia County Public Health Services. <br /> — <br /> s - Lot Size/Acreage V` y`FC-'r <br /> -...•:E rj:,t%�� City __ <br /> Job Address k'} <br /> Address- Phone <br /> Owner's Name d: <br /> 23 J icense No. Phone <br /> Contractor _Address -- _- - <br /> TE OF WELL/PUMP'. NEW WELL O WELL REPLACEMENT Idonitoring:'dell <br /> l" DESTRUCTION ❑ Out of Service Bell / <br /> (PUMP INSTALLATION 0 SYSTEM REPAIR CD OTHER O <br /> YP <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL PITS/SUMPS OTHER WELL ""�"- ,.--'r`'� f• �, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> M Industrial - ❑ Open Bottom O Manteca Dia. of Well Excavation <br /> �dJ <br /> Cl Domestic/Private L1 Gravel Pack ❑ Tracy �. Type of Casing_—_. <br /> Specifications•-t. ` <br /> I l Datta Depth of Grout Seal" Type-of Groul_ <br /> I'I Public F1`Other <br /> 4 <br /> I I Irrigation Approx. Depth 1 1 Eastern * Surface Soul Installed by J <br /> State Work Done <br /> Repair Work Done ❑ Type of Pump P -- <br /> _ <br /> Sealing Material & Depth <br /> Well Destruction- D Well Diameter <br /> __Depth �- Filler Material i`De$th r--'� <br /> T TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 R PAIRJADDITION I I DESTRUCTION f I (No septic system permit led-il'p661ic rower is i• <br /> available within 200.1eet.l p <br /> Installation wiil serve: Residence — Commercial , Other .� <br /> Number of living units: Number of bedrooms G1 <br /> ' Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments �v <br /> PKG. TREATMENT PLT, O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line Vl! <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Nurnbar <br /> SUMPS <br /> Cl Distance to nearest:..-^Well Foundation Property Line' ti <br /> r r <br /> DISPOSAL PONDS O <br /> I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, mate Iawa, and <br /> rubs and regulations of the San Joaquin County <br /> Horne 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 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 /> the work for which this permit is issued, I shall employ persons subject to workman's eompensa-` <br /> candies the following: "1 certify that in the pertormence of <br /> tion laws of California." ` <br /> TheaDate: <br /> pplicant must for 11 req d inspections. Complete drawing on reverse side. <br /> � ~ � <br /> i ned Title: I <br /> EPARTMENT USE ONLY p <br /> Date1 l �f r Z <br /> Application Accepted byAC..� ; <br /> Date Final Inspection by <br /> Pit or GrouOnspection by <br /> Additional Comm-,ints: , <br /> Y c, <br /> Applicant - Return all copies to: San Joaquin County Public Health Seivices <br /> Environmental Health Permit/Service4� <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 9.5201 <br /> FEE CK ECEIVED BY DA PERMIT'NO. <br /> INFO AMOUNT OUE AMOUNT REMITTED <br /> ''`e•. EX.11-24 IREV.r n 5! -7.���A// f7 - <br /> —5H 54.26 i .. 1 - <br />