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i <br /> APPLICATION 'FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FRQM DATE ISSUIED, <br /> (Complete in Triplicate) <br /> Application in hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> spplication is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Pob <br /> oaquin County Public Health Services. <br /> Address _�?-5 ' a% --A' � � City t Size/Acreage f ►� <br /> Owner's Name 's A:r ,L, ,P0�VIOYVAddress � � Phone 4 • Il` ) <br /> yG`•ayeZ C . <br /> Contractor_ C Address License No. Phone <br /> YPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Kell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private 0 Gravel Pack7 ❑ Tracy Type of Casing. Specifications f 1 <br /> i'1 Public (-1 Other 11 Delta Depth of Grout Seal Type of Grout rW <br /> I I Irrigation _Approx. Depth I1 Eastern Surface Said Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ r <br /> Well Destruction 0 Well Diameter Sealing Material i Depth �} , <br /> Depth hiller Mstertal i Depth nn <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONDESTRUCTION I 1 INo septic system permitted if public sewer is 1 ! <br /> available within 200 feet.) 3 <br /> Installation will serve: Residence x Commercial_ Other <br /> �umber of riving units: .—,- Number of bedrooms <br /> V GharaCter of sod to a depth of 3 feat: <br /> Water table depth <br /> SEPTIC TANK. ❑ Type/Mfp Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ r ` Method of Disposal <br /> Distance to nearest: Well , <br /> _f i_�� Foundation�f� Property Line J� � I <br /> /LEACHING LINE ❑ No. & Length of lines 2 Total length/size I S <br /> �/. FILTER BED 0 Distance to nearest Well Foundatio r- Property Line 10 <br /> vqr a _ <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> d <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 t <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature rtifies the following: "I certify that in the parformance of the work for which this permit is issued, I shall not <br /> ploy any person in such rnannar as subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following• "I certi hat i the patio once of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." y <br /> i <br /> applic n s r all requir spa, io s. Complete drawing on re side.AdA <br /> Ar - <br /> pn Title: IF Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by . �t �-��, �� <br /> Date _ Area <br /> Pit or Grout Inspection by Data Final Inspection by Date_�iC f13 <br /> D � ; <br /> Additional Comments: <br /> I <br /> Applicant - Return all copies to: San Joaquin County Public Healt Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 85201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> EH � <br /> e <br /> lAEV.lisi <br /> Ex14I. s� r�� 11 ♦ t�® C �/ /� �/�� <br />