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APPLICATION SR # c,-7-= <br /> i <br /> SAN JOAQUIN COUNTY PUBLIC HEALT JND* 11 ..,w <br /> ENVIRONMENTAL HEALTH DIVI A <br /> 445 N SAN JOAQUIN, PHONE (209} � <br /> P 0 BOX 2009, STOCKTON, CA 52, <br /> ...�..r.....� <br /> PERMIT EXPIRES 1 YEAR FROM DAT <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 In made in compliance with San Joaquin County Ordina ce No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public He Services. ri <br /> I , <br /> Job Address :51:s, D, - _ � City Lot Size/Ar.reage <br /> Own r' Namer. t_� Addre D1hone r � <br /> ' " r <br /> Address ilPhonen1laclo � nAt <br /> _ _ <br /> TYPE Of WELL/?UMP: NEW WELL ❑ WELL AEPLACEMl n DESTRUCTION ❑ Out of Service WL-11 ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X 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 SPECIPICATI91lt- <br /> Industrial Open Bottom a Manteca Dia, of Well Excava ab.f1t Dia. of Well Casing <br /> 17 Domestic/Private ❑ Gravel Pack L-1 Tracy Type of Casing_ 1i Specifications <br /> I"I Pawl 1-] ther r Deha Depth of Grout Seal Type of Grout <br /> I I I r �2 Approx. 0 1 i Eastern Surface Seal Installed by <br /> Af ep WortAl300 ___�T`yyppe of Pump �_ H.P. tae Wl Done alf <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth A i <br /> Depth Filler Materirl i Depth a <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I Ill septic system permitted it public sewer is <br /> available within 200 feet.1 <br /> Installation will serve: Residence_ Commercial_ Oti7er <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 rl <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to neest. W/,- <br /> Foundation_ Property Line _ <br /> LEACHING LINE ❑ No. b Length of lines Total length/siz <br /> n <br /> FILTER BED n Distance to nearest: W Founcation1�1' <br /> .R 'ra"�i�rt ne <br /> �� � 1 <br /> SEEPAGE PITS 11 Depth _Size r^li, ar ��'L, _ <br /> SUMPS LI Distance to nearest: Wetl Foundation alle L . <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that i have prepared Phis application and that the work will be done in accord a quin 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"performanLwork 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 Cab " Contractor's hiring or sub-contracting signature <br /> certifies the follow' g: "I certify that in the performance of the work for which this permit is issued, lat2ornploy Petal subject to workman's companea• <br /> cion tavra of or la." <br /> The spoils /t st call Icer al req r inape ti s, pies drawing on reverse aid . <br /> Signed Ji r . Title: s� y i�i� 4"lErale: <br /> PR DM E�h <br /> WPSE ONLY <br /> Application Accepted by _ Date Area LA/F <br /> Pit or Grout Inspection by Date - Final Inspection by k Date <br /> Additional Comments: Ar <br /> APP - Return all copies to: San Joaquin County Public Health Services <br /> 437a-s�ooa - �--vv RB�z <br /> Environmental Health Permit/ServicesrJ q p.7+ <br /> 445 N San Joaquin, P n Box 2009, Stkn, C 9FEE ` a I <br /> n INFO AMOUNT DUE AMOUNT REMITTED KSH FiEGE1VEp 9Y OAT - 1 P(p i-NO, <br /> �( ° <br /> EH 13•2+IAEV.i l e s1 fl `�� 1 (� r e t a r ti/%"rr � "l <br /> ill: / I i t' r l _ / 1 / f ',' ;'JS <br />