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APPL I CAT I ON q3 -7 J <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH WRVICES <br /> ENVIRONMENTAL HEALTH DIVISION '�� �� <br /> 7 <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 9 <br /> f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> V#,;)-9 <br /> L (Complete in Triplicate) <br /> t Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> j 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 /> 1 ^ l <br /> Job Address® � ` City Lot Size/Acreage <br /> l L Owner's Name ` t �.Scz+�— Address I.S O Phone 3 j <br /> Contractor �� � LIS Address Z\vrd (= License No. �c�s'1�1 Phone - 4 <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well Gl <br /> L PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS <br /> L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial © Open Bottom 0 Manteca Dia. of Welt Excavation Dia. of Well Casing <br /> [7 Domestic/Private 0 Gravel Pack C Tracy Type of Casing_ Specifications <br /> I'1 Public I:1 Other fl Delta Depth of Grout Seal Type of Grout <br /> d <br /> 11 Irrigation _Approx, Depth 1 I Eastern Surface Seal installed by 1\-- <br />} Repair Work Done L3 Type of Pump H.P. State Work Done - <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION iae REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is 1 <br /> L <br /> available within 200 feet.) <br /> Installation will serve: Residence XCommercial_ Other <br /> Number of living units: 4 Number of bedrooms 3_ <br /> Character of soil to a depth of 3 feet:' r C Water table depth d r <br /> SEPTIC TANK fE�= Type/Mfg JMt?(- Capacity No. Compartments <br /> L PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well __NCrQ Foundation 1 Property Line <br /> LLEACHING LINE 0- No. & Length of lines Total length/size l r <br /> FILTER BED [] Distance to nearest: Well :0 ,Foundation ��, Property Line <br /> LSEEPAGE PITS J�4_ Depth Size ibNumber <br /> SUMPS LI Distance to nearest: Well 265:9 Foundation �� r Property Line <br /> DISPOSAL PONDS 0 <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 />,h The applicant 74411 <br /> all for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: [�rr),OX Date: - z,g-' 93 <br />$ <br /> I L' f FOR DEPARTMENT USE ONLY <br /> i r L <br /> Application Accepted by _ __ _ Date ,Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> LEnvironmental Health Permit/Services <br /> a 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT.REMITTED RECEIVED BY DATE PERMIT'N0. <br /> •` INFO �i / L.�/- 'rf' rdCAS�Hy! �//� <br />! EH 13-24(A EV.I M 5) AJ �/ �r 00 !� r � v v `"R r 7 �J / �(i / <br /> EH t4•2e <br /> r <br />