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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> KNVIRONN"TAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EgPIRES I YF�AR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby tsade_to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> application Is made in cooglliance With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joe.quin County Public Health Services. <br /> Job Address _ fl'j' + © /ls��� C.,ty��/� Lot SSZe/Acrerge <br /> Owner's Name // / Address _ ems/� Phone <br /> /� ,yld.,�c atf <br /> Centtactor//lQ��i!'yP/� c� Address_ �Q , lzl4e License No. AftAg phone <br /> TYPE OF WELLIPUMP: NEW WELL D WELL REPLACEMENT l7 DESTRUCTION 0 Out of Service Ne-I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER D Monitoring Wel Q <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 /> r Industrial D Open Bottom D Manteca Die. of Well Excavation Dia. of Well Casing {� <br /> [.i Domestic/Private ❑ Gravel Pack L] Tracy Type of CasingSpecifications <br /> I"1 Public Il Other Ll Delta Depth of Grout Sea! Type of Grout <br /> i Irrigation — Approx. Depth 1 1 Eastern Surface Seat Installed by <br /> Repair Work Done LJ Type o1 Pump H.P. __ State Work Done— <br /> Well Destruction Q Well Diameter Sealing Material L Depth <br /> Depth Filler DSaterial 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 FiEPAIF1 ADOPTION I ! DESTRUCTION I I [No septic system permitted if public sewer is <br /> I avaifabfn within 200 feet.? f� <br /> Installation will serve: Residence_ Commercial_ Other <br /> Numfxr of living units; Number of bedrooms <br /> Character of soil to a depth of 3 feet ------Water <br /> Water table depth <br /> SEPTIC TANK 0 Type/Mfg � Capacity No. Compartments <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Well Foundation Y Property Line <br /> LEACHING LINE 0 No. 6 Length of lines w + Total length/size <br /> FILTER BED Cl Distance to nearest: NJeU_ Founcatwn+- Property Lire <br /> SEEPAGE PITS 11 Depth Size � Number <br /> SUMPS LI Distance to neVest: Well _ _ Foundation Property Line <br /> DISPOSAL PONDS Li <br /> I <br /> I hereby cenify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances. state laws, and <br /> riles and regulations of the San Joaquin County <br /> Horne owner or licensed agent's signature certifies the fcliowing: "I certify that in the porformance of the work for which this permit is issued, I shad not <br /> employ any person in such manner As to become subfeci to workman's compensation laws of California.'"Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the pertormsnc•of the work for which this permit is issued, I shalt emploY persons subject to workman's compensa- <br /> tion laws of Californla-" <br /> The applicant Ust I t0 Ire tions. Complete drawing on reverse sides <br /> L �/�/��e.t� <br /> Signed Title: —_�/w �— WgJ <br /> 7� Date: _ <br /> FOR P TMENT USE O <br /> Application Accepted by r <br /> — Date_ Area J <br /> Pit of Grout leaps tion by Date Final Inspection bLe <br /> Additions! Comments: OiW I I a`ft <br /> APPlicant - ReLurn all copies to: San Joaquin County pubiir H alth Services <br /> Environmental Health permit/Services <br /> 445 N San Joaquin, x 2009, Stkn, CA 95241 <br /> FEE <br /> del (�T <br /> INFO AMOUNT DUE AMOUNT REPuTTED ECEIVED SY 0 E PERMt1 No. <br /> Eli1 <br /> 3-24 fhfV. t� `1 �t / <br /> EH 1420 y,J�J 11 — 61� // <br />