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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O 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 /> Job Address 3pmo kksso w 1t E q t— A¢u�_Ity JeAcq Lot Size/Acreage S© / /0 G ' <br /> Owner's Name W11114d'i Address - .d / Phone <br /> Contractor Ry� Address -0a 3 j�D License No. Phone `(:J�� <br /> TYPE OF WELL/PUMP: NEW WEL1 WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION:❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANKKli,AL�cc <br /> ALFLD. PROP. LINE <br /> FOUNDATION AGRICUEII( iN�tLS��tSUMPS _ <br /> INTENDED USE TYPE OF WELL ( tOBLEM AREA T T SP CIFICA I ✓ <br /> n Industrial ❑ Open Bottom ( ❑ Manteca a.. ti Fria. of Well Ca <br /> 1 <br /> Ca <br /> Domestic/Private ❑ Gravel Pack Trac 'f�e � Specifications <br /> 1"I Public Cl Other P Delta De J, 4XIXET <br /> t of pro746�Type of Grout l� q <br /> 1 1 Irrigation �.Approx. Depth I I Easter NMIgA&MAMtS�y.L� rr.Tn. cJ <br /> Repair Work Done U Type of Pump --- IAMS RUV _D1ilWb <br /> � <br /> Sealing Material i D Q <br /> Well Destruction ❑ Well Diameter Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION" DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence� Commercial_ Other <br /> Number of living units: / Number of bedrooms_ .L_ <br /> Character of soil to a depth of 3 feet: 1. f Water table depth i <br /> SEPTIC TANK T <br /> ype/Mfg CL:vc-Als-;-¢`c . Capacity t'`" No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line •''+ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size IT) <br /> ) <br /> FILTER BED (A Distance to nearest: Well .� <br /> •� Foundation �'O Property Line <br /> P00 <br /> SEEPAGE PITS 11 Depth /�� Size Number <br /> SUMPS LI Distance to nearest: Well L r Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> rules and regulations of the San Joaquin County <br /> Home 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 workman's compensa- <br /> tion laws of California." <br /> The applicant must all for all wired insPections. Complete drawing on reverse <br /> side. <br /> Signed X Title: Date: `� •(C <br /> MENT USE ONLY <br /> Application Accepted byDate Ara �r ' l• <br /> Pit or Grout Inspection by Date I Inspection by <br /> - Date <br /> Additional Comments: J Ftjtj�"ll 1jr` .* r <br /> Applicant - Return all copies to: San Joaquin County Public ;��Cervice�sAL <br /> ' TH DIVISIOIJ <br /> Env445iNoSari quin, P O <br /> alHealth eBox 20 P <br /> CK —1 <br /> INFOFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24 IREV. 0� �Q ? r <br /> EH 1426 K. 1 �J °�1.7 <br />