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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-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 7v M4 City t Siz creage <br /> Owner's Name J� Address +�_, c�� �—�+fPhone <br /> Contraclor L CG$5 Address <br /> S/7� �re1r Q-e--T Ale License No. � �r�_Phone 7 ��� <br /> TYPE OF WELL/PUMP: NEW WELL " WELL REPLACEMENT t- DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION Ao" SYSTEM REPAIR D OTHER ❑ Monitoring Well G3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t2 <br /> FOUNDATION AGRICULTURE WELL � OTHER WELL =� PITS/SUMPS 2!= <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation Dia. of Well Casing <br /> C7 Industrial rp�3pen Bottom C7 Manteca <br /> r-141mestic/Private Cl Gravel Pack7 ❑ Tracy Type of Casing__ Specifications <br /> 11 Public Cl Other Fl Delta Depth of Grout Seal fo Type of Grout <br /> I I Irrigation ALO_Approx. Depth I I Eastern Surface Seal Installed by OP14 <br /> Repair Work Done CJ Type of Pump H.P. f IV_ State Work pone , <br /> Well Destruction ❑ Well Diameter Sealing Material Depth <br /> Depth Filler Material fi Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet.] <br /> Inst lotion will serve: Residence— Commercial_ Other <br /> Number o 1 its: Number of bedrooms <br /> Character of soli to a dep feet: Water table depth <br /> SEPTIC TANK ❑ Type/M g pacify No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: W Fou Property Line <br /> LEACHING LINE ❑ No. $ Le of Eines Total length/sr <br /> FILTER BED Cl D' ce to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Y., Number <br /> SUMPS Ll Distance to nearest: Well 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 cenify 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 mut all for a requir d insPections. Complete drawing on <br /> reverse side. <br /> Signed Title: - _ Date: <br /> FO DEP MENT USE ONLY 3 <br /> Application Accepted by Date Area <br /> Pit or iCiroLt Inspection by Dat Final Inspection by ito`sem ------- <br /> Additional <br /> — <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services 4 <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 9520 c <br /> FEE AMOUNT DUE AMOUNT.REMITTED C K RECEIVED BY ATE PERMIT'N0. �� <br /> INFO <br /> i�11f uti 6 <br /> l' <br /> . EM 53.24 TREY.t nsr +9 <br /> EH 14.28 2� -1 1465 <br />