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APPLICATION 4 <br /> f <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.1$62 and the Rules and Regulations of San <br /> oaquin County Public Health Services. <br /> rJob Address '� !� t City t3Lot Size/Acreage <br /> Owner's Name rn" Q r — Address Phone <br /> : <br /> j k�Contractor t ~ C ddress r "'y "License No. Z 7 Phone v <br /> + I WELL REPLACEMENT M DESTRUCTION C1 Out of Service Well G] <br /> TYPE OF WELL/PUMP: tXAELL n , <br />{ SYSTEM R. AIR C7 OTHER ❑ Monitoring Well ❑ <br /> PUMP INION ❑ ., <br /> DISTANCE-TO NEAREST: SEPTIC-T - --SEWER- -INES- DISPOSAL FLO. PROP. LINE <br /> t r FOUNDAAGRICUL RE WE OTHER WELL PITS/SUMPS <br /> IN USE TYPE OPROBLEM AREA -C RUCTION SPECIFICATIONS Q <br /> C7 Industrial ❑ Open B ❑ Manteca Di Well Excavation Dia. of Well Casing <br /> Ca Domestic/Private ❑ Gravel ❑ Tracy ype of sing Specifications11 Public -t' 1-� Others_ I1 Deltas Depth of GSeal Type of Grout I ,i Irrigation [ —.Apph— l I Eastern"- `""Surface Sealelnstalled byRepair Work Done' L7 .Type of PP. _^_.State Work OonaWell pestruciion' ❑ "Well DiamI Sealing Material &.Depth <br /> "s Depth Filler Material & AeP1 y <br /> PE OF SEPTIC WORK:, NEW INSTALLATIO REPAIR/ADOIT1f]N I i DESTRUCTION INo septic system permitted if public sewer is <br /> 1 t ava�ilablVwrthin 200 feet.) � <br /> rte'"" +mr'�• 11 � p <br /> s Inatalla'tion will serve:=-Re3tlIdence X Commercial Other 1 3 �C �lr�e7�lalr ' <br /> Number of living-units: ___L Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK°" Type/Mfg Capacity ' © No. Compartments <br /> PKG, TREATMENT PLT'. ❑ f Method of Disposal <br /> r <br /> `t Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER.BED ❑ Distance to nearest: XWell� Z Foundation ProperRy Line <br /> SEEPAGE PITS Depth �o�5 F —_Sill �� T Num or <br /> SUMPS # i l k Distance to nearest x1Netl t Foundation �� Property Lina <br /> OSAL PONDS DC7 t" <br /> I hereby'certify that I have'prepared this applicatiort_and..that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> l 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 /> empioy.any person_in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:j.Tcertify that in the•pertormance of the work for which this permit is issued. I shall employ persons subject to workman's compensa- <br /> tion taws bf,Caiifomis."v1- �L__ 4,.A <br /> The applicant t call fo all required ' speetions. Complete drawing on reverse side. Q <br /> Signed X �-/ �r-r'`'�j - Title: �� _ Date: l 7 <br /> FOR DEPARTMENT USE ONLY <br /> e... q� <br /> { Application Accepted by — Date Area <br /> Pit or Grout Inspection by Date Final Inspection by I to <br /> Additional Comments: ' <br /> Applicant! - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> t 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 <br /> IFEE <br /> NFO t AMOUNT DUE AMOUNT REMITTED K It CASH RECEIVED BY DATE PERMIT*NO. <br /> . Eli'13.2�IREV.iiN51 <br /> EH 14.20 .`�."'7• ttfV e. - G-4 11 r.3 ' /I �+ <br /> V - <br />