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APPLICATION �D g <br /> SAN JOAQUIN COUNTY PUBLIC HEALT ICES 4Ga7 <br /> ENVIRONMENTAL HEALTH DIVI �{/11FF <br /> 445 N SAN JOAQUIN, PHONE (209) �0 <br /> P O BOX 2009, STOCKTONI CA <br /> PERMIT EXPIRES 1 YEAR FROM DAT 1�Ssi RG.�U <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 coopllence with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ('�� <br /> Job Address Z0�� ` ` SSS City Q,�J Lot Size/Acreage <br /> Owner's Name C-rx-11L\\r Lpr�35 Address SAdv%-e— Phone <br /> Contractor a.4-r :3==M Address r ' L <br /> f ' � License No. RZC"L�i Phone ' <br /> — - - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well L1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 SPECIFICATION�e <br /> L) Industnsl ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ptWell Casing r� <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ B (il�,otions <br /> FI Public 17 Other fl Delta Depth of Grout Seal ,Nd Grout <br /> Irrigation —ADMox. Depth Eastern Surface Soul Installed by - '1 t <br /> 1-7 <br /> Repair Work Done U Type of Pump H.P. _—EiStkjio{(�0"i <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth A/� '{�r r <br /> Depth <br /> Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 9- REPAIR/ADDITION I I DESTRUCTION I I (No septic system pormilteFdIf public sewer is Q <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other_-S``s�� !.t <br /> Number of living units: _ Number of <br /> bedrooms r <br /> Character of soil to a depth of 3 feet: - trtsWptj9hn Water table depth <br /> SEPTIC TANK IiiL_Type/Mfg y E'G Capacity_— No. Compartments <br /> PKG. TREATMENT PLT. ❑ , Method of Disposal <br /> r <br /> Distance to nearest: Well Foundation Property Lina���D r (� <br /> LEACHING LINE 9L No. 6 Length of lines ���� Yb ' Total length/size a ` <br /> FILTER BED ❑ Distance to nearest: Well rr <br /> Foundation Property Line/�• ' <br /> SEEPAGE PITS W Depth Size -3(o [/ Number <br /> SUMPS LI Distance to nearest: Well Foundation -70 Pro r perry Lina BOO <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state [am, 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, 1 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 /> conifies the following: "I certify that in the performance of the work for which this permit is issued. 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> Tho applicant must call r yR require m ions. Complete drawing on reverse side. � (� <br /> SignedX /�rrsa Title: OLD n� C/-Date: >i -� F <br /> FOR DEPARTMENT USE ONLY f <br /> Application Accepted by Date Z Z q 1 res <br /> t r Grout Inspection by � !>Z ate '1- Final Inspection by � ��a(s <br /> Additional Comments: 6 <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> 9 Z I INFO AMOUNT DUE AMOUNT REMITTED CA EC IVED BY DATE <br /> PERMIT NO. <br /> EH t3"24(RIV.r�+ai I /7 L v 6��y L® r'L_Z­ ✓ V T <br /> EH u.a) VV <br />