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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> f 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 /> ZI 6 -aL 1 <br /> Job Address City - Lot Size/Acreage <br /> Owner's Name N 1`/ ����?•e 44100�Address C.�� Phone. (a o <br /> Contractor Hddress 6 License N4 Phone fi <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well 0 <br /> I jPUMP INSTALLATION ❑ SYSTEM REPAIR L1OTHEA ❑ Monitoring Well <br /> DISTANCE TO NEAREST:!SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> 3 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE j TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17 Industrial :❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C7 Domestic/Private '❑ Gravel Pack n Tracy Type of Casing_ Specifications <br /> Cl Public 11 Other n Delta Depth of Grout Seal _TYpe M,r.,out I <br /> I i Irrigation Approx. Depth I I Eastern Surface Seal Installed by � . ` <br /> Repair Work Done U 4T ype of Pump H,P. e' <br /> — StWk-D _I + <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth / r <br /> Depth Filler Material i Depth.-''�_ I <br /> TYPE OF SEPTIC WORK; NEW lNSTALLATIOINREPAIR/ADDITION I I -DESTRUCTION I I INo septic system permitted if public sewer is <br /> ravailable within 200 feet.l: a J <br /> installation will serve:, Residence Commercial_ tltisr- V.1 <br /> } <br /> Number of living unite` i Number of bedrooms f } <br /> Character of soil to a depth of 3 feel:.. `. - /l Water ta4le depth <br /> SEPTIC TANK O ,Type/frAig t Capacity- No. Compaitments i <br /> PKG. TREATMENT PL7. C] •�y / �hlathod of Disposal <br /> Distance to nearest: Well 70 Foundation_/_40 Property <br /> may' <br /> LEACHING,-L'fNE—�-❑ No. & Len Length of lines t,��.-,.., <br /> 8 �` Toyllllength/size <br /> FILTER BED LJ Distance to nearest: Well Foundation _2 b J� Property Line ✓� <br /> f <br /> SEEPAGE PITS PIK Depth 2Z AK Size Nuinber <br /> SUMPS Ll Distance to nearest: <br /> - ! <br /> We r Foundation —` Property Line <br /> DISPOSAL PONDS 0 i <br /> I hereby certify that I have•prepared this application and that the work will be-done-in-accordance with San Joaquir).t<aunty ordinances, stale laws, and <br /> rules and regulations of the San Joaquin County 13 • ; <br /> Home owner or licensed agant's signature certifies the following:,"I certify that in the perforrtjance of theYw ,h Jor which this permit is issued, IIshall 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.' l <br /> I The applicant must Cal I required Ins do Complete drawing on reverse <br /> Signed Xr 7iNe: Dots: <br /> x _ DR DEPARTMENT USE ONLY 3 r 1�l ,Ir,I <br /> Application Accepted by D Z Date !.2 �� Area <br /> i•:y a <br /> Pit or Grout Inspection by" Date Final Inspection by Date G Z <br /> Additional Comments: 0.7 r« / <br />—APP1.-icant—=^^RetuA'-all cOpies"to;-5an Joa7quid"C4yunty-Pup1'ic"He8:17th Services' <br /> Eovirgnmentk1 Health"permit/Service"s <br /> 445 N�'Sari+sJoaguln,c P'"0-8oai�2009, Stkn,''-CA,"95201 <br /> lir - � <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY T <br /> / q� CASH PERMF7'N <br /> . Ek 13-24IREV.linN H/ / / r •I ' �� 7 a�r J 3�O <br /> EN 7�7D I / <br />