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APPLICATION 00 !J <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �1Q <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N SAN JOAQUIN, PHONE (209)468-3420 Work coeSj-b; Ct <br />P O BOX 2009, STOCKTON, CA 95201 t( .Z. h - <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED accred 6v rIV' <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 Pufbblic Health Services. __ <br />Job Address lJ[ r11a:n c JeC+ City �4�JL-rl�War --o7f Size/nAcreage �Q� 11/7–Q���_ <br />Owner's Name Arn retia -n ress 51' Lpil�, 14@--retrAr. �;_ I��QQT �7ne- ern <br />Contractor Address lJ License No. �r� Phone <br />PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br />DISTANC NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />n Industrial n Bottom ❑Manteca Dia. of Well Excavation Dia. of Well Casing <br />Cl Domestic/ Private ❑ Grav ack ❑ Tracy Type of Casing_ Specifications <br />I"I Public (:1 Other P Delta Depth of Grout Seal Type of Grout <br />I I Irrigation �. Approx. Dept 11 Eastern Surface Seal Installed by <br />Repair Work Done U Type of Pump H. P. — State Work Done _ <br />Well Destruction ❑ Well Diameter Sealing Material & Depth <br />Depth ler Material At Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AD ON I D TRUCTION I I (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: Residence _ Commercial _ Ott -ter <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK O Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. O Method of Disposal <br />Distance to nearest: Well Foundation Propert ne <br />LEACHING LINE 0 No. & Length of lines Total length/size <br />FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS (I Depth Size Number <br />SUMPS LI Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS ❑ <br />1 hereby certify that 1 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 all fo II reAuirey ipspections�,p9mplete drawing on reverse side. J/, <br />Signed X � �" Title: ze: ' ' � j Date: <br />FOR DEPARTMENT USE ONLY <br />Application Accepted byf Date Area <br />Pit or Grout Inspection by <br />Additional Comments: <br />Final Inspection by <br />Applicant - Return all copies to: San Joaquin County Public Health S <br />, i E rsental Health Permitc <br />k <br />A,�t„�,v�t jT, � 5 N jfin-�ilJoaquin, P O Box 2009 2009, S <br />. EH 1.24 (REV. I/ e sr <br />EH 11.20 <br />N <br />S1� 00o3 6- <br />FEE <br />INFO AMOUNT DUE <br />AMOUNT REMITTED <br />CASH CK i <br />RECEIVED BY <br />DATE PERMIT No. <br />AA -)'a 1r__Q.--'1 <br />I 17S. 61 E) <br />(ql <br />T <br />t1— <br />7 oZI, <br />K9 3 75 <br />