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f _ i <br /> APPLICATION1 <br /> SR # 0 <br /> 3 �= SAN JOAQUIN COUNTY PUBLIC HEALTH SERvtqEENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN,PHONE(209)469-34 0 r_ <br /> P O BOX 388,STOCKTON,CA 95201-0388 1 ' `' <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSN <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 application is made in compliance with San <br /> Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br /> Job Address F `�, <br /> City Lot Size/Acreage <br /> Owner's Name f�G[l�ty 4 (gal',o Address Phone ` 6z <br /> ContraCto Lr ! !t bt Address ! / License ko. F'hon <br /> TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT nDESTRUCTION O Out vi Service tiie11 ❑ <br /> PUMP INSTALLATION C SYSTEM REPAI,. L-1OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK yC ire SEWER LINES 1190 DISPOSAL FLD. PROP. LINE 3A <br /> FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L] Industrial ❑ Open Bottom 0 Manteca Dia, of Well Excavation <br /> Dia. of Well Casing <br /> I p[�omestic/Private OLGravel Pack ❑ Tracy Type of Casing_ �. <br /> a 1'1 Public Specifications <br /> I-1 Other it Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation &W(Approx, Depth I I Eastern Surface Seat Installed by <br /> Repair Wort Done v Type of Pump H.P. , <br /> State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth — Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 1 INo septic system permitted if public sower is <br /> Installation will serve: Residence_ Commercial Other available within 200 IeeLl <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKU Type/Mfg CapacityWater table depth h <br /> � _ <br /> PKG. TREATMENT PLT. ❑ ` Nofij" <br /> 20!Distance to nearest: Well Foundation property. ` .1'. <br /> LEACHING LINE �4 <br /> Cl No. l3 Length of lines t <br /> FILTER BED � <br /> n Distance to nearest: Welt FoundTotal leng�s� ' (`)` N T Y <br /> ation PAWKICikAF LT�d SER`JiCi_S <br /> f SEEPAGE PITS 11 Depth Sire <br /> Number <br /> SUMPS <br /> LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ �--- Property Line <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, <br /> rules and regulations of the San Joaquin County and <br /> j� 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 /> Ilion laws of California." <br /> The applicant Inyst call for all required ins tions. Complete drawing reverse side. <br /> I Signed X Lv Title: t IlGN q <br /> Date: .3 6 <br /> I FOR DEPARTMENT USE ONLY ' <br /> I Application Accepted by <br /> 1 agate ��1J Area <br /> { Pit or(EI spection by <br /> 1# Final Inspection by Date , ' L� <br /> Additional Comments: ✓ 2Z 2 ! /��_ <br /> Applicant - Return all c pies to: San Joaquin County Public Health Services r(4 <br /> i Environmental Health Permit/Services <br /> .1 445 N.San Joaquin,P.O.Boz 388,Stockton,CA 95201-0388 <br /> �/ FEE cz <br /> AMOUNT DUE AMOUNT REMITTED CR <br /> INFO tAtH RECEIVED BY DATE PERMIT'NO. <br /> 4 13-24 N 1l. InEY.riNsl �u!r DV J� , �r/ V� +� ✓�V <br /> �J ! to <br /> T. I <br /> i <br />