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T f. APPLICATION" <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 1 YEAR FROM DATE ISSUED <br /> r (Complete in 'Triplicate) <br /> t err `, r ^# i r• - <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 Mules and Regulations of San <br /> Joaquin County Public HeaUh Services t22"- ,� l/ <br /> Job Address ' v=f`r� ( �u, Cit dl Lot Size/Acreage / <br /> Owner's Name Address Phone <br /> Contractor 4 Address License No.7 Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 171 DESTRUCTION ❑ out of Service Well ❑ <br /> a� PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER p Monitoring Well <br /> Well L3 <br /> -�-�- SEWER LINES d DISPOSAL FLD. PROP. LINE <br /> l � <br /> E 01STANCE TO NEAREST; SEPTIC TA�KFOUNDATION AGRICULTURE WELL THEF1 WELL PITS/9bMrS Q Il'- <br /> Y f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Die. of Well-Excavati n Dia. of Well CasingDi <br /> domestic/Private �(Gravel Pack L] Tracy Type of Casi g_ Specifications <br /> ['1 Pi+blit f-1 Other n Delta Depth of Grout Seal Type rout <br /> 3 4ji( <br /> rrigation _Approx: Depth 1 Eastern Surface Seal Installed by j <br /> 1 r <br /> Work Done L7 Type of Pum H.P. ` — State Work Done T 7�.. <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth C c �� <br /> Depth <br /> Filler Material & Depth <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> r ^ Number of living units: Number of a drooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> B SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments <br /> -PKC. TREATMENT PLT. ❑ _ Method of Disposal <br /> Distance to nearest: well Foundation Property Line ' <br /> LEACHING LINE ❑ No. & Length of lines c Total lengthtsize <br /> FILTER SED ❑ Distance to-nearest: Well Foundation Property.Line <br /> r <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> l DISPOSAL PONDS ❑ <br /> ,,,I heieby 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 /> t rules and regulations of the San Joaquin County <br /> -Horne 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 parson in.suah manner as to become subject to workman's compensation taws of California."Contractor's hiring or subcontracting signature <br /> cenifies,the following: '.'f comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenaa- <br /> tion`lavw of California.'; ,.. s <br /> The.applicant mus Cfor -r ired ' speptions, Complete drawing on reverse si e. <br /> Signe Date: <br /> 7/,�/ <br /> F0 EPARTME T USE ONLY <br /> Application Acceptedsby-- �~ Date LA L Area 7- 11 <br /> �� q Final,lnepection by Data g <br /> Pit Gro' nspection by Date 7 <br /> f Add tronal'Comments: ' &- 4. { N d JAI <br /> T -wo✓S uA"i <br /> 'Applicant - Return all copies to: San Joaquin County Public Health Service <br /> I Environmental Health Permit/Services 94(f bw .Says (u-cci <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH <br /> - 53-2�tlEv.MIS) j311- 3 <br /> 4-2e <br />