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APPLICATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTI <br />ENVIRONMENTAL HEALTH DIVI; <br />445 N SAN JOAQUIN, PHONE (209) <br />P O BOX 2009, STOCKTON, CA <br />S&P, <br />3"°x-/3 <br />;ixE5 i rww rRom I) ,1.. lj . <br />(Complete in TTiplicate `I — <br />Application is hereby made'to Sap Joaquin County for a permit to cerstruct and/or install the workhere a �eecrUT <br />application is wide in cotepliaace with Sen Joaquin County Ordinance No. 549 and 1862 and the Rulea and Regulations of San <br />Joaquin County Public Health Services. <br />•.JA__.._ 1–i��r.J,l L'7 �.tlCl(Y�tic� �+�Uh Lot. Size/Acreage <br />Phone <br />Owner's Name <br />Address — _ <br />1(64'','�P—S. Phoneme <br />Contractor <br />Address ! License No. <br />TYPE OF WELLIPUMP- <br />MEW WELL D WELL REPLACEMENT 7 DESTRUCTION ❑ Out of Service well 0 <br />PUMP INSTALLATION 0 SYSTEM REPAIR Ll OTHER ❑ Monitoring Well C� <br />DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO, PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SU&4PS <br />INTENDED USE <br />TYPE OF WELL QROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />n Industrial <br />❑ Open Bottom ❑ Manteca Dia. of Well Excavation __ Dia. of Well Casing <br />,.I Domestic/ Private <br />❑ Gravel Pack ❑ Tracy Type of Casing_ _ ___�_— SpecHicarions <br />I'1 Public <br />Cl Other fl Deice Depth of Grout Saa) Y Type of Grout <br />I I irrigation <br />— Approx. Oepth I I Eastern Surface Seal Insietled by <br />Repair Work Done LD <br />Type of Pump H.P. _ _.�v State Work Done _ <br />Wall Destruction ❑ <br />Well Diameter Sealing Material k Depth <br />Depth Filler Material L Depth <br />TYPE OF SEPTIC WORK: <br />NEW INSTALLATION i I REPAIR/AODiTrOM P DESTRUCTION I I (No septic system permitted it public sewer is <br />avaAable within 200 feet.? <br />Installation will serve: <br />Residence _'L Commercial-- Other T� <br />Number of riving units: <br />Number of bedrooms , <br />Character of soil to a depth of 3 feet: <br />Water table depth -76SEPTIC <br />TANK <br />t�1� <br />!i1 Typa)Mfg `� GOh �cc�:C` Capa:ity 1Z60 No. Compartments <br />PKG. TREATMENT PLT. <br />❑ Method of Disposal tca�S <br />Distance to nearest: Well Foundation ?O'er Property Line Irl <br />LEACHING LINE <br />D No. & Length of lines �_ 1� Iength/size <br />FILTER BED <br />' �Tolal <br />D Distance to nearest: Weil l6 / _ Fourraatron Property Line <br />SEEPAGE PITS <br />11 Depth 2 - Size _ Number _ f <br />SUMPS <br />Lf Distance cc newest Wall(U / Foundation 17 Property Line 20 <br />DISPOSAL PONDS <br />O <br />I hereby certify that 1 have prepared thin application and that the work will be dorvb in accordance with San ,Jaaquin 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, "t certify that in the pe+formance 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 compansahon laws of California." Contractor's hiring or subcontracting signature <br />certifies the following: "I certify ttiat 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 CalifornW," <br />The applicant must c f aft re r <br />i1-110115- Complete drawing on reverse side, <br />signed Title_ k yOQ oaten _ i 4' <br />/ FOR DEPARTMENT USE ONLY <br />Application Accepted by _ Date <br />Pit or Grout Inspection by Date Final Inspection by <br />Additional Convnenis: <br />NI <br />Applicant. - Return all, conies to: San Joaquin County Public licaith Servicera <br />Enviroamental Health Permit/ServIcas �\ <br />445 N San JoaquiniyP,lO Box 2009, Stkn, GA 95201 � 9\ O 1J 6 , t(� <br />FEE Y'` t INFO �tMHr QtJE AMQU{NT++ REMITTEDK H� RECEIVED BY DA <br />it <br />! <br />EH •7e <br />in <br />