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APPLICATION <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 I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance'vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Z Zf 7 7i`VCity Size/Acreage _Ayt''y��' <br /> t <br /> Owner's Name 1 r f G Address 2 <br /> — —- - _ Phone <br /> 4 <br /> 49 <br /> ContfactorMtkilcr Address Pr�;s ('r !9 ,License fait �43.5�`�_Phone �2 <br /> TYPE OF WELL/PUMP: EW WELL>9�_ WELL REPLACEMENT F1 DESTRUCTION 0 Out. of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK I� 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 /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 7,3 <br /> 7�44`omestic/Private _Dlq_�ravel Pack n Tracy Type of Casing_ r Specifications <br /> I'1 Public I-i Other n Delta Depth of Grout Seal T f GroutTIL_ L14 <br /> yp o <br /> hrigationQ .Approx. Depth I l Eastern Surface Seal Installed by / <br /> Repair Work Done ❑ Type-of Pump H.P, State Work Done — <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> DepthFiller Material & Depth <br /> TYPE OF SEPTIC'WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted d public Wwer'Is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_: Other <br /> Number.of living units: , Number of bedrooms <br /> 9 <br /> Character of coil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT..❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑'- No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest; Well Foundation - Property Line !!! <br /> r <br /> SEEPAGE PITS j' <br /> It Depth Size <br /> Number <br /> SUMPS LI " Distance io nearest i',Well Foundation Pro <br /> party Line : <br /> DISPOSAL PONDS ❑ x' <br /> I hereby certify that I have prepared this application and that the.wotk will be done in accordance with San Joaquin county ordinances, state laws, <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, 1 shall-not i <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 shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant[ ust ill for all required ins ctions, Complete drawing on averse side. 3 <br /> Signed X _ <br /> Title: �Q Date: ev <br /> F OT USE ONLY ::, <br /> d <br /> Application Accepted by Date _r �Y Z- Area J <br /> ab <br /> Pit. rput apection by ate incl Inspection by Date r <br /> Additional Comments: LG. <br /> s <br /> Applicant - Re urn all copies to: San Joaquin County Public Health Services i <br /> En ironmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 d <br /> - i <br /> FEE AMOUNT DUE AMOUNT REMITTED CK ~RECEIVED 8V DATE PERMF7'rr0. <br /> INFO CASH <br /> • EH 1311 IAEV.I/H 5)},f I� <br /> EH 14-2e Yv iV <br />