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1 <br /> 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 /> (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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. _ / <br /> R 2 �N )\) Q. �f AW �7�- 330—G9 <br /> I <br /> Job Address City Lot Size/Acreage <br /> 1 <br /> Owner's Name Address ,r t Phone <br /> Contiactor�j .Lf'm "r -_Address �`►i r License Nod 1 a��Cg Phone (,25_-y/;D'" <br /> TYPE OF WELL/PUMP: NEW WELL i❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L) OTHER>< �aoltit�ing Well E3 <br /> DISTANCE TO NEAREST: SEPTIC TANK N A SEWER LINES IC DISPOSAL FLD.4_ PROP. LINE 2.0 I <br /> FOUNDATION AGRICULTURE WELL _611-21 OTHER WELL 21.2PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E1 Industrial ❑ Open Bottom C3Manteca Dia. of Well Excavation Dia. of Well Casing A i <br /> [1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing- Specifications I� — <br /> I"I Public Other 'f?0FU hfan Delta Depth of Grout Seal Type of Grout JJ EAI! <br /> 11 Irrigation — Approx. Depth XEastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump �� H.P. State Work Done <br /> Well Destruction ❑ Well Diameter fa � Sealing Material & Depth Rw <br /> M50 V_k Kq Depth / Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR1ADDITION 1 I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence_ Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE M No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll 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 ordinances, state laws, and <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, i shall 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 applicant m cat)for all required in coon n on reverse side. <br /> t C+4- Z �4 3 Data: ( � 4� <br /> Signed X Title: <br /> FOR DEPARTMENT USE ONLY <br /> t• <br /> Application Accepted by Date ILS 3 Area �� O <br /> Pit or Grout inspection by ate Final Inspection by (` ~ Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCAS <br /> 11 <br /> INFO H RECEIVED 8Y DATE PERMIT NO. <br /> `yrs 4 103D <br /> EH 13,24IREV.tiH5i �Gje© ' �� <br /> EH 14.26 f �C <br />