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APPLICATION:-FOR PERMIT f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <br /> • ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> P LIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application in hereby meds 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 Se es. 7� ` <br /> Job Address �1�___�se <br /> 'Ve R city Lot Size/Acreage ?S.� <br /> Owner's Name �`�..t"t el�(yT 1 Address �Lx hons�.. � • � l <br /> Contractor Address V 4`f" Licenser No.4O Seo Phone-3160 <br /> TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT F.) DESTRUCTION L1 Out of Service Well U <br /> PUMP INSTALLATION C3 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ industrial ❑Open Bottom y O Manteca Dia. of Wait Excavation Dia.of Well Casing <br /> . n Domestic/Private d Gravel Pack ❑Tracy Type of Casing_ Specifications <br /> I'1 Public J' 1 ' n Other, n Della Depth of Grout Seal Type of Grout <br /> I i Irlivation I ,xl L-Approx, Depth I I Eastern Surface Seal Instaaed by <br /> Repair Work Done ❑ Typsof Pump H.P. State Work Done_ <br /> Well Destruction ❑ Wall Diamelm Sealing Material i Depth <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f DESTRUCTION (No septic system permitted it public sewer is <br /> available within Z00 feet.) <br /> Installation will serve: Residence Commercial_,--, Other <br /> Number of living units. Number o ooms <br /> Character of soil to a depth of 3 feet: d a r4 1 Wath table depth - <br /> SEPTIC TANK. G- TVPa/Mfg 0,0' C: L �^ Capacity —M.-No. Compartments <br /> PKG.TREATMENT PLT.❑ - Method of Disposal <br /> Distance to nearest: Well"_`Foundation a Property Line &al - ` <br /> t LEACHING LINE 13T-'No. A Length of lines - 0 Total iangth/size ^� <br /> {i FILTER SED ❑ Distance to nwaak WellFoundation I Property Line d� <br /> SEEPAGE PITS I4/6epth �S� c Size Y Number <br /> SUMPS. LI Disunce to nearest: Well j/O! Foundation _¢ 0 r'Property Lina <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 ro <br /> Home owner or Gcansed agent's signature certifies the following: "I comity that In the performance of the work for which this permit is issued, I shall not <br /> ampioy any person in such manner as to become subject to workman's compensation Laws of California."Contractor's hiring or subcontracting signature <br /> OvAifiiet the following:"I carW 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 /> Theacall for all req sd in tions-Complete drawing on reverse side. <br /> Signed! <br /> Sigl Title: 21Gft -- Date: a <br /> j { &3=== <br /> LY <br /> Application Accepted by �4L=�, - Dow Area IQ Z k Z-- <br /> i <br /> Ph pec <br /> or Grout Inspection .-tivi Data (Final Inspection's}by Deter 3J'0 2 <br /> Additional Comments: <br /> i, Applicant - Return all copies to:- Stn Joaquin County Public Health Services <br /> $avironnental Health Permit/Services <br /> 448 N Sao Joaquin, P O Box 2008, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED 9Y DATE PERMIT NO. <br /> INFO J <br /> .EN13.2+ra[v-t/M Sl <br /> Er+to 2s <br />