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x . APPLICATION <br /> r f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCSTON, 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 M <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 Public Health Services. _,� <br /> �ob Address -3 l �.!'�f�G2 fG-. C'u -� 4t Size/Acreage <br /> -%NJ 1T?f <br /> �/' /1 <br /> ]` s <br /> owner's Name �r 1 Y4`141� Addr�es�t 7-� ) d t>�( 7�,� Phone ` <br /> GonlractorF Address [P `� License No� -7d y _Pitons *J III <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT D DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring well E7 <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 /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing W <br /> ['I Domestic/Private Cl Gravel Pack7 ❑ Tracy Type of Casing_ Specifications <br /> Il Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump .��H.P. _ State Work Done _ <br /> Well Destruction ❑ Well Diameter a.�^l t Sealing Material & Depth <br /> Depth : Cr Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1- REPAIR/ADDITION I I DESTRUCTION1<11No septic system permitted it public sewer is <br /> I ' ; available within 200 feet.) <br /> Installation will serve: Residence— Commercial`= Other <br /> Number of living units: 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. ❑ Method of Disposal I <br /> Distance to nearest: Well Foundation Property Line <br /> k <br /> LEACHING LINE 0 No. & Length of lines '� Total length/size ~r <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> F <br /> t <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 <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 j <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 1 <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 must call for all required inspgcti Iota drawing on reverse side. <br /> Signed %FtTi <br /> =AFITMENT <br /> Date: <br /> ONLY lr �J <br /> Application Accepted by rim r Date T1 1 3 Area 2 <br /> Pit or Grout Inspection by Date Final Inspection byff/4�141 , <br /> 4 <br /> Additional Comments: <br /> Applicant -- Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE I <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED <br /> RECEIVED BY DATE PERM17'NO. <br /> . EH E3.24[REV.r/n SI -7r [1]/L 4 <br /> EH 14$e- "`---"'((( fff V I4 <br />