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' r APPLICATION <br /> I r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES X YEAR FROM BATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby ttmde,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coaipliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address OW0,6 I SI��w'��y,� &N( c, City 4}1Q_t���X Lot Size/Acreage <br /> e p qr r <br /> Owner's Name ozw_ �� Address ��� _ /1 'ea&C Zmam;, Phone O.7 �.�ZJ <br /> Conhactor1& Address EjLicenseNb:�,°2 Sf3Sf3"Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT t"I DESTRUCTION ❑ Out of Service Well O <br /> PUMP INSTALLATION D SYSTEM REPAIR C) OTHER G Monitoring Nell 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK ,4'JJ-(-'SEINE NES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> C' Industrial U Open Bottom O-Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C:}jDomestic IPrivate ❑ Gravel Pack D Tracy Type of Casing_ Specifications <br /> i'l4Public i-1 Other II Delta-' Depth of Grout Seal Type of Grout <br /> I Irlr,ripation _Approx. Depth I I Eastern Surface Seat tnstalled by <br /> Re;yair Work Done Ll Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material d Depth <br /> it <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I IDESTRUCTION i I (No septic system permitted if public seweriis <br /> available within 200 feet.I =t <br /> Installation wRI.serve: Residence Commercial— Other <br /> i <br /> Number of living units: _/L Number of bedrooms !!j� t � <br /> r� t�haracter of sod to a depth of 3 feet: c F Water table depth 0 <br /> 'SEPTIC TANK Jr Type/Mfg &V _e,r. Capacity�TpQ'�";'" Nd.-Compartments f <br /> ("'PKG. TREATMENT PLT. Cl '►' r r Method of Disposal <br /> r Distance to nearest: Well 74 Foundation �Q Property Line <br /> LEACHING LINE 0 No. & Length of lines :'�� Total length/size d <br /> FILTER BED n Distance to nearest: Well '� Foundation 0— Property Line irp/fi _f <br /> S4PAGE PITS lA Depth Site _ _-7 Number <br /> SUIIMPS LI Distance to nearest: well ¢-Foundations/ Property Line <br /> DISPOSAL PONDS Q a l <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> ruts 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 /> certifies the following: "I certify that in the performance of the work'for which this permit is issued, I shall employ persons subject to wofkman's compensa- <br /> tion laws of California." t <br /> Thbapplicant must N for all required inspections. Complete dra%iWg on t <br /> reverse side. _20f_Signed Title:. 4 .ZI/l t Date: <br /> 'FOR DEPARTMENT USE ONLY <br /> Ap lieation Accepted by ¢� �d I`t Date ^� Area <br /> rte--- <br /> Pitru Grout Inspection ry Date Final Inspection by ^Date <br /> 4- <br /> I t <br /> Ad irtional Comments: <br /> Applicant - Return all copies to: San.Joaquin County Public .Health Services <br /> EnvironmentaljHealth Permit/Servfcos <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> y t <br /> INFO CK A <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT N0. <br /> . EM 17.14 REV.ren 51�JC1( <br />