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F <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445PNOS OXJ2009INSTOCKTON, CAPHONE 95201R YM41vienT <br /> E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAI 2 <br /> (Complete in Triplicate) UBL! O)'QUI . <br /> Application ie hereby made to San Joaquin count fore E/VoON�f�C�gAH�rEAL-AM0, <br /> ,C0041r� <br /> application ie made in compliance with San Joaquin County Ordinance 549aando1862$end thetall eRuleslaAned l ijig i�P,4o This <br /> Joaquin County Public Health Services. ��Bo San <br /> t Job Address r-% r- City SJ0C-V &%^ Lot Size/Acreage <br /> Owner's Name aV Address1419 <br /> e <br /> Phone <br /> Contractor [arnn Address <br /> • License No. Phone <br /> � 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION XOut of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring WellAc,r' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE +lam <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationr <br /> Dia. of Well Casing 2 <br /> CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- PO4-L Specifications <br /> i'I Public M Other R Delta Depth of Grout Seal 40-14r <br /> Type at Grout me" /_1c►µ <br /> I i Irrigation S Approx, Depth I I Eastern Surface Seal Installed by_ tE.`JL[+C.ivc-e—%- <br /> Repair Work Done 0 Type of Pump H.P. " <br /> Well Destruction �~ State Work Done T <br /> FI Well Diameter ­74— Sealing Material & Depth Lcal <br /> Depth t Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I i DESTRUCTION J'1 (N, septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial` Other <br /> Number of living units: Number of bedrooms <br /> ,f <br /> Character of soil to a depth of 3 feet: Water table depth _ <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal F <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of tines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> R <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to-nearest:: - .Well Foundation . ,Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> rules and regulations of the San Joaquin County q o my ordinances, state laws, an <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 ahall not <br /> 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 California." <br /> The appiica ust call for all required in";tions.-Complete drawing on reverse side. <br /> Signed X ` �/�.� �•� �y� ,•� q <br /> Title: Date: <br /> 3 <br /> FOR DEPARTMENT USE ONLY n <br /> Application Accepted by Date 7 �J <br /> Area <br /> Pit or Grout Inspection by ate Final Inspection by <br /> yz Date <br /> Additional Comments: 3ZZ <br /> or 0 <br /> 1J <br /> Applicant - Re rn c pies t an oaqu n uty-ru c ea l ervices fir` <br /> Environmental Health Pe mit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMIT-TED RECEI <br /> ED <br /> INFO �j,,� CASH VED BY DATE <br /> //�!hy PERMIT'NO. 29 <br />• EH 13-T4IAEV.iiHSa WV ,t—r) <br /> EH 14-Ie UU/// rt/LJ ��OD <br /> x <br /> � i <br />