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APPLICATION I{' <br /> SAN YOAQUIN COUNTY PUBLIC ERVICES <br /> ENVIRONMENTAL HEALTH <br /> 445 N SAN JOAQUIN PHONE ( 3420 ,...r� <br /> P 0 BOX 2009, STOCKTON, : iACTI <br /> { CC <br /> PERMIT EXPIRES 1 YEAR FRO�A 1f "l�r� <br /> (Complete in Tripli aM11" <br /> Application is hereby glade to San Joaquin County for a permit to constructid r herein described. This <br /> application Is made in conplianee 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 147 V Atop: __ City `` Lot Size/Acreage <br /> Owner's Name 64K�-=ai r / — Address &,�2 '{{�/�� gS�/? one <br /> Contractor Address 6WA.e. Lit r Phone "Q f <br /> TYPE OF WELL/PUMP! NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRIC7 OT .� . ,4°n �4 ng Well ❑ 4 <br /> t DISTANCE TO NEAREST: SEPTIC TANK A -_ SEWER LINES M& -__ __ ..ilDISPOSAL FLD.'N PROP. LINE �� I' <br /> j FOUNDATION AGRICULTURE WELL /`� +OTHERj�WELL I PITS/SUMPS N <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ i� Specifications <br /> I'! Public EI Other 1­1 Delta Depth of Grout Seal. 1 Type of Gtouiaz=LYRZ <br /> I i Irrigation Approx. Depth Pit Eastern Surface Seat Installed by <br /> Repair Work Done U Type of Pump H,P. _�' State(Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth'f Nr <br /> I Depth <br /> Filler Material & Depth <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I l i INo septic system permitted it public sewer is <br /> �1 i available within 200 feet.I <br /> Installation will serve: Residence_ Commercial_ Other r f <br /> Number of living units: Number of bedrooms rD <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity I� No. Compartments <br /> I <br /> PKG. TREATMENT PLT. ❑ # Method of Disposal <br /> Distance to nearest: Well Foundation Property Line G <br /> Ik � <br /> LEACHING LINE Cl No. & Length of lines I Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation I :Property Line F <br /> SEEPAGE PITS 11 Depth Size I Number <br /> SUMPS LI Distance to nearest: Well Foundation F ItProperty Line 1 <br /> DISPOSAL PONDS ❑ :i <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 i I� <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the pe,formance 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 compense- 1 <br /> tion laws of California." <br /> The applicant c 0 fo wired i pections. Complete drawing on reverse side. {i <br /> Signed X Z Title: . pate: <br /> + % li <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by I'Data f Area <br /> 5 Pit or Grout Inspection by Date r ` ` Final Inspection by Date <br /> Additional Comments: —_ �r7 [ 00*--Li��� I . <br /> Applicant - Return all copies to; San Joaquin County Public Health Services <br /> Environmental Health Permit/Serv;ices <br /> 445 N San Joaquin, P O Box 2009;, 5tkn,I,CA 95201 <br /> I ;i <br /> lFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY il DATE PERMIT'MO. <br /> y <br /> EH13.24(REV.l i n 51 43q r 1�f j! ! • f D.9 I q R3 <br /> EH 14-2e 1 6 <br /> I� <br />