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I' APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 70 <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-- 1 3 kt vz bAk t2 a_ City Lot Size/Acreage �1 <br /> Owner's Name r >Z le 4 + t` d Addres<S 2 41V 60'44 KCS ka 4'1• Phone `akC o <br /> Contractorb&rA- P�*N Address( <br /> A X -AL S74I✓ License Ng/�._ _Phone 64-176-1.r <br /> TYPE OF WELL/PUMP: 1 NEW WELL ID WELL REPLACEMENT 1-1 . DESTRUCTION Cl Out of Service well If <br /> - <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D t OTHER ❑ Monitoring Well <br /> r r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL;FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL . PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing <br /> f.eDomestic/Private Cl Graver Pack ❑ Tracy Type of Casing- Specifications <br /> I'1 Public (.1 Other!t n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _ Approx. Dep I Eastern Surface Seal Installed by <br /> i' Repair Work Done 61e Type of Pump H,P. State Work Done e <br /> rl , <br /> � Wel! Destruction ❑ Well Diameter Sealing Material & Depth <br /> j <br /> -Depth" giller Material&`Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 ) DESTRUCTION I i (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve' .Residence al Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: S Water table depth <br /> SEPTIC TANK-- 3 0Tyl/Mfg """`"'" °"" Capacity No. Compartments e <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 <br /> # FILTER BED C_] Distance to nearest. Well Foundation Pr4erty Line <br /> SEEPAGE PITS I I Depth,E Size _ Number',4 <br /> SUMPS L! 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 Carifornia.'i 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 ibmploy persons subject to workman's compensa- <br /> Non laws of California." IP <br /> i <br /> The applicant ust call for all required inspections. Complete drawing on reverse <br /> side. <br /> Signed K /-Title- <br /> Date: 0-7 <br /> F <br /> OA_DEP_AR7.MENT�USE.nNLY,. - <br /> 6 _C1J <br /> ApplicationAcceptedby Date Qr� r Area <br /> Pit or Grout Inspection by Date - Final Inspection by Date <br /> Additional Comments: F _ <br /> Applicant - Return all copies to: San Joaquin County-Public Health Services <br /> ' c Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE i <br /> f T INFO AMOUNT DUE, AMOUNT REMITTED GRECEIVED BV ASH ATE PERMIT'NO. <br /> r . EH 13-24IRFV.I/K51 <br /> Elf 11.26 !!!Y <br />