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APPLICATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N SAN JOAQUIN, PHONE (209) 469-3420 <br />P O BOX 388, STOCKTON, CA 95201-0388 <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 application is made in compliance with San <br />Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br />Job Address �« 3 N - MAD I _,�D'y -S { <br />Owner's Name �G C" wL07 Address <br />Contractor,5l"&—gu 1,1 Address <br />City Lot Size/Acreage _ <br />1=rp 5 I s t <br />yJr_W&.wnw ai one <br />ffL6 /5 cense No. 5— Pho <br />-17 If L9 11S <br />LL, C—A 71 Z <br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 7 DESTRUCTION ❑ Out of Service Well ❑ <br />PUMP INSTALLATION C SYSTEM REPAIR E,T �M Monitoring Well �Q <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ?" 25' DISPOSAL FLD. NAC PROP. LINE �7m <br />FOUNDATION�I O() AGRICULTURE WELL tt OTHER WELL PITS/SUMPS Lr, <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Ci Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br />154�11 <br />❑ Gravel Pack ❑ Tracy Type of Casing -Specifications ^^�,,�� <br />I'I Public (1 Other 1-1DeltaDepth of Grout Seal �Groul J31' ++ �''rLc <br />I I IrriUauon +7- Appfox. Depth astern Surface Seal Installed by e <br />Repair Work Done LJ Type of Pump H. P. __ State Work Done _ <br />Well Destruction O Well Diameter Sealing Material i Depth <br />MoN IS W, I t1f6 Depth _ Filler Material i Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ' I REPAIR/ADDITION I I DESTRUCTI <br />I I (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: Residence _ Commercial _ Other <br />AMOUNT DUE <br />Number of living units: Number of bedrooms PAYMENT <br />C K H RECEIVED BY <br />Character of soil to a depth of 3 feet: cm am dft y,(t. ble depth <br />v PERMIT NO <br />SEPTIC TANK O Type/Mfg Capacity ff1lVVddVV''FFCC partments <br />PKG. TREATMENT PLT. O MAY 1pvte,ORjo( Disposal <br />Distance to nearest. Well Foundation _ 2AN I <br />P1JR1 ICH AI TH SFRUI('F$ <br />LEACHING LINE C) No. 6 Length of lines ENVIR(}QNFPJlXA6h4®LTH DIVISION <br />FILTER BED Fl Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS I I Depth Size Number <br />SUMPS LI Distance to nearest: Well Foundation Property Lina <br />DISPOSAL PONDS O <br />1 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 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 Californ a." <br />The applicant st call for all require peetiods.�._drawing on reverse side. <br />h 3 <br />Signed X Title: Date:4Z f 7 <br />R DEPARTMENT USE ONLY <br />Application Accepted by Date o" Area <br />C <br />Pit or Grout Inspection by Date l Final Inspection by Date <br />Additional Comments: m <br />Apj Lir ant - Return all copies to: San Joaquin County Public Health Services y� <br />Environmental Health Permit/Services <br />445 N. San Joaquin, P.O. Box 388, Stockton, CA 95201-03 <br />C rZ <br />EH 1334 (REV, r i n 5) <br />EH 14 26 <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />C K H RECEIVED BY <br />DATE <br />v PERMIT NO <br />