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APPLICATION. <br /> j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 2 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Ilealth Services. <br /> t <br /> Job Address 0IVA� �/�L City ✓ � Lot Size/Acreage <br /> Owner's Name ko eeA'ddress V WA r"_ "d <br /> ,�' / P-2 7 q5-2.01 ey 7 1 9 <br /> l Contractor f/ 1 ddress License No. Phone <br /> i <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT, ❑ DESTRUCTION 0 Out of Service Well O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 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 0 Open Bottom O Manteca Dia:oT Well Excavation Dia. of Well Casing <br /> [I Domestic/ ❑ Gravel Pack0 Tracy Type of Casing__ Specifications <br /> I'1 Public 1:1 Other { I-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done v <br /> Well Destruction O Well Diameter ( Sealing Material & Depth `/ <br /> Depth I Filler Material & Depth <br /> PE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION1 I (No septic system permitted if public sewer is <br /> available within 200 feet.) C <br /> Installs ill serve: Residence_ Commercial_ Oth®r' - <br /> 4 Number of living u _ Number�_of_bedrooms <br /> Character of soil to a depth o J Water tab t th <br /> SEPTIC TANK O Type/Mfg Capacity' Compartments <br /> PKG. TREATMENT PLT. ❑ '".$ I ; Method of Disposal <br /> Distance to Barest:: Well ou n ( Property Line G <br /> LEACHING LINE Cl ngth of lines i ` Total lengt <br /> FILTER BED -] Distance to nearest:, Well 1 Foundation Property Line <br /> SEEP GE PITS 11 Depth Number <br /> MPS CI Distance to nearest: We11 # Foundation Property Line <br /> f ISPOSAL PONDS :0- i <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 <br /> I 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 C ifornla." <br /> The applicaus `c for all <br /> /rhe d ns ions.•Co .plate drawing on rove se side. <br /> Signed X �v � Title: __- / cl ° Date: �v <br /> F ENT USE ONLY <br /> Application Accepted by Date ^f" L(� ( 2-' Area <br /> h <br /> Pit or Grout Inspection by Date Final�Inspection by Date <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 95261 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK i RECEIVED BY ... DATE PERMIT'NO. <br /> . EH 13-24(REV.Iixsl �r! �� <br /> I EH 14.26 [� e d� t O 4 Q <br />