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APPL I CArT I ON <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, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 •YEAR FROM DATE ISSUED <br /> x -,.,(Comp.lete in Triplicate) <br /> F, <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 mede`Tn con>pliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> I Joaquin county Public Health Services. <br /> C <br /> 9'/a��yl� y � it Lot Size/Acreage <br /> Job Address <br /> jt <br /> Na e dress of Phone`7 <br /> L*--��O? <br /> nor pl <br /> Phone f <br /> Con actor d s <br /> TYPE Of WELL/PUMP: NEW WELL Cl /' WELL REPLACEMENT [-1 ESTRUCTION ❑ Out of Service We11 Cl <br /> PUMP INSTALLATION "•y/ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �� Type of Casing--------.! Specifications <br /> (1i�or1lestic/Private ❑ Gravel Pack Cl Tracy Yf3 g- . <br /> I'1 Pub is 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Iriig tion ; Approx. Oapt I Eastern dace 5ea1 Installed by <br /> Repair' ork Done4 ❑.Type of Pump H.P. State Work D <br /> Well D structian �. D Well Diametrer� �� Sealing Material 8 Depth ,f <br /> Depth-J— <br /> TYPE <br /> �! xlov <br /> Filler Material A Depth <br /> TYPE < F SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> ,> _ �Co <br /> M'sta lotion will servo: Residersce m <br /> .�.��,,,, mertiial Other` <br /> .Num Char kr q1t,of to a depth _ Number of bedrooms. µ"ms - -� v <br /> .. - ��, of 3 feet: '_.Water table depth <br /> SEPTI TANK ❑ Type/Mfg Capacity No.-Compartments , <br /> PKG. EATMENT PLT.❑ } Method of Disposal `\ <br /> Distance to'nearest: Well Foundation Property Line' <br /> LEACHING LINE 0 No. & Length of lines Total langth/sizeY x <br /> ' FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAd E PITS 11 Depth Size Number <br /> SUMP L1 Distance to nearest: Well Foundation °—Mroperriline \ <br /> DISPO AL PONDS ❑ <br /> I hereb certify that I have prepared this application and that.the work will be done in accordance with San Joaquin county ordinances, siate•1aws, and <br /> rules ar d regulations of the San Joaquin County <br /> } Home caner 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 /> emplay 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 he of California." , <br /> The ap tic st call for inspections. Complete drawing on re a Si 6. �. <br /> Sign Title: Date: 64: /A,- <br /> r OR DEPARTMENT USE ONLY <br /> / r Z � ,� <br /> X 1 <br /> Applisa#ion Accepted by ate, Area <br /> i , l <br /> Pit or drout Inspection by Date Final Inspection by 1.t� Date 1 L,7— <br /> l. <br /> +IF{ Additional Comments: _. <br /> y <br /> Applicant - Return all copies to: San Joaquin County Pubiic�Health Services <br /> t . Environmental Health Perraii/Services <br /> 445 N San Joaquin, P O 136x,.2009, atkn, CA 95201 <br /> FfE AMOUNT DUE AMOUNT REMITTED <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH17•2/IREV.1inaf iso �� - a <br /> { EH 11•2E � <br />