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Q000 <br /> PERMIT EXPIRED APPLICATION <br /> AP( OAQUIN COUNTY PUBLIC HEALTH SER CSR # <br /> Permit may have expired wit�iouf ENVIRONMENTAL HEALTH DIVISION AlD # <br /> Work being completed or inSpeCte#$N SAN JOAQUIN,PHONE(209)469-342 <br /> by Environmental Health Division P o Box 388,STOCKTON,CA 95241-0388 FAC# <br /> MWIT ES 1 YEU FROM DATE ❑ �� <br /> (Complete in Triplicate) I� <br /> r �, <br /> Plication is heicby riiade to 171 <br /> San Joaquin Cotlrity for a peimii to construct andlor iitstal3 the work))algin desciibad:This'appincation is made in compliance with San <br /> Joaquin County Devalopment Title Section 9]1103 and Section 9=1115.3 and the Rule's`end Regulations 9f San]oaqutn County Public Health Servirxs. <br /> Job Address City Lot Size/Acreage <br /> MOeM>A <br /> Owner's Name Address ZZZ- - U e6Le- gtl25�e""rte <br /> Contractor f &&%L_ 110r7 aAW,51S"l"_ License No.a nL.�,—Phar+e <br /> 5,45 442.rn> <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service dell 0 <br /> PUMP INSTALLATION G. SYSTEM REPAfR-O OTHER. G3• Wnitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK , �_ SEWER-LINES ---� sDJSPOSAI FLD. PRDP, LINE <br /> FOUNDATION .• AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PAYMENT <br /> Cl industrial 0 Open Bottom a Manteca Dia. o1 Well Excavation <br /> (:1 Domestic/Private O Gravel Pack 0 Tracy Type of Casing_ gro ;�t <br /> I'I Public I:1 Other fl Delia Depth of Grout Seal .T] <br /> rpa of Grout <br /> I I Irrivation _Approx. Depth I 1 Eastern Surface Seal Installed by i SAN a(jp, ulri{0019 MOti <br /> Repair Work Done 3 Type of Pump J'.H.P. Stage Work <br /> `- "Sealing Material i Depth t I <br /> Well Destruction O Well Diameter ng <br /> Depth Piller Haterial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( I DESTRUCTION V IND septic system permitted if public sower is <br /> Instillation will servo: Residence_ Commercial— Other <br /> v'R available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of sofa to a depth of 3 feet: �Watar table depth <br /> SEPTIC TANK o Type/Mfg Capacity No.Compartrtients <br /> PKG. TREATMENT PLT. D Mathod of Disposal <br /> Distance to nearest; Well Foundation Property Line <br /> L£AChING LINE C No. & Length of lines Total length/size 1 <br /> FILTER BED ❑ Distance to nearest: Well Founcauon Property.Lina �i <br /> SEEPAGE PITS [ I Depth Sirs Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 workmen'■ctxnpensa• <br /> tion laws of Caiifornla." <br /> The app"folsctions. Complete drawing an reverse side. <br /> SignedTitle: &ONIM Date: 1,4r)Af <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by --• 4 _ Date <br /> �V,�! Area_ 7- �� <br /> Pit or(trout Inspection byDate Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Fnviroomental Health Permit/Services <br /> 445 N.San Joaquin,P.O.Boa 388,Stockton,CA 95201-0 /}O <br /> FEE�'Lr INFO AMOUNT DUE AMOUNT REMITTED �j RECEIVED BYim 13-24 v <br /> EHt� IREV.iiHbl f a <br /> r <br />