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+ APPLICATIONi� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH, DIVISION <br /> k 445 N SAN JOAQUIN, PHONEI (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 13 <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 /> t application Is made in compliance with San Joaquin County Ordinance No.'1! 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.,, <br /> �, --�" [ Ci A01— � Loc Size/Acreage <br /> Job Address <br /> PhoC� so <br /> ►7 <br /> Owner's Name <br /> P✓r<�r r W S r! UC'VC Address !J�66~ <br /> �+,✓��-r-� 'Ad° <br /> ss' <br /> ir+,1�1 y l Phon f�� 2�7�y�0► <br /> Contractor Address f 7 5 License No. <br /> TYPE Of: WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> 11 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR n OTIJER ❑ Monitors Well <br /> /ng <br /> DISTANCE TO NEAREST: SEPTIC TANK 3LY SEWER LINES 3Jr h DISPOSAL FLD. J i PROP. LINE !v <br /> FOUNDATION 30i r AGRICULTURE WELL 0 y OTHER WELL PITS/SUMPS + <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ,t/ <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation J% Dia. of Well Casing / <br /> ' Specifications SO 14 <br /> dl! <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> P <br /> i'I Public her b 0!,I/I? fl Delta Depth of Grout Seal f m� Type of Grout <br /> I I Irrigation NApprox. De. 1 I I Eastern Surface Saul Installed by ' <br /> Repair Work Done U Type of Pump H.P. '1 State Work Done _ F <br /> Well Destruction ❑ Well Diameter . frtl Sealing Material tr Depth <br /> Depth Cr M w Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system paraw4ed if public sewer is <br /> F available wit net.i <br /> i <br /> Installdtro iii serve: Residence — Commercial_ Other <br /> Number of living urn Number of bedrooms !' <br /> Character of soil.to a depth of 3 fee . Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> { PKG: TREATMENT PLT. ❑ i Method of Disposal <br /> Distance to nearest: all Foun a _ Property Line <br /> .1 <br /> LEACHING LINE ❑ No. & th of lines Total lengt <br /> FILTER BED ❑ tante to nearest: Well Foundation Pr <br /> SEEPAGE PIT It Depth Size '] Number up <br /> 444 SUMPS LI Distance to nearest: Well Foundation :i SP�r`oDect"6msj�- { <br /> UPk <br /> DISPOSAL PONDS ❑ Iv JA[.T1cci��SlIE Vf(%F-5 V <br /> I hereby certify that I have prepared this application and that the work will be done in iccorda rtnr�e&4TM t�.Cr>4 t ces, state laws, and <br /> rules and regulations of the San Joaquin County g �V, <br /> I] <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 permiilis issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California <br /> The appl must call for all r ad inspect s. Complete drawing on reverse side.l' M <br /> Signed X `� Title: - i� � Data: <br /> Sh i <br /> '1194 ENT USE ONLY <br /> ApplicalloAepted by , Date / Area <br /> � Pit or Grout inspection by Date Final Inspection by <br /> �+VDate S <br /> fddilional Comments: 1r <br /> 'tt Applicant - Return all copies to: San Joaquin County Public Health Services -3c p� <br /> 4.• Environmental Health Permit/Services V <br /> 445 N San Joaquin, P 0 Box 2009, Stka, CA 95201 <br /> 3; <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> tH,3-2,IRfV „m Sr :231 <br /> CH 1 <br /> ..26 <br />