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f � <br /> `APPL;I CATS[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 E%PIRES 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. 5119 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 13 City Lot Size/Acreage <br /> \ - O. Phone <br /> Owner's Name V ..! � C7 Address � � c <br /> Contractor A_c Addres 11 IF License No3 Phone or ' <br /> TYPE OF WELL/PUMP 'a NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ <br /> :*` <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> It FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE '•TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> n Industrial ❑ Open Bottom ❑ Manteca ­Dis:-of Well Excavation Dia. of Well Casing <br /> Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public f_1 Other (-1 Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —Approx. Depth. I Eastern Surface Seal Installed by <br /> Repair Work Done 'Mr Type of Pump H.P.f:.^� " _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Material 6 Depth i <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION l I� REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sewer is 1 <br /> available within 200 feet.),. <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> i 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 DisposalY s <br /> h Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE D No. & Length of tines Total length/size <br /> t FILTER BED ❑ Distance to nearest: Well Foundation_..- Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> ` SUMPS LI Distance'to-naarest:_'. 'Well Foundation, Property Line <br /> i <br /> DISPOSAL PONDS G7 <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 SanJoaquin County. �. -■ <br /> Home owner or,licensed agent,a'signatute certifiei"the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any peron 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 California." <br /> s The appli u call for all requi inspec ' ns. Complete drawing on rave sid/e7 <br /> I . <br /> Signed X Title: �P s Date: ! 4 <br /> r <br /> _ FOR DEPARTMENT USE ONLY <br /> _n 5 <br /> ' QilCE -L� _ JL&MN�.�.ti Date �2 Area <br /> Application Accepted by -- <br /> Pit or Grout Inspection by Date Final Inspection by 1�1Date 6 �� <br /> f <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public.Health Services <br /> Environmental Health Per t/Services <br /> X 445 N San Joaquin,_Z-4; x 2009, Stkn, CA 95201 <br /> t <br /> FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. <br /> I. <br /> EH132.4IREV.i In 5r <br /> Z <br /> k <br /> Flt t.•2a 111..••!!ll���, <br />