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APPLICATION <br /> SAN JOAQUIN COUNTY-P HEALTH SERVICES <br /> ENVIRONMENTAL TH paa <br /> LTH SERVICES <br /> HEAL1 L:JN't'Y- LI{G HEA <br /> PHONE (V9 408-3fiT�+4E0�4�,�'TAI,ItEALTH DIVISION <br /> 445 N SAN JOAQUIN, <br /> P o Bog 2009, sTocgTox, CA 95IAI. PERMIT <br /> PRM R S .1 YEAR R M DATE- ISSUED <br /> i (Complete in T licate). <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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San i <br /> Joaquin County Public Health Services. 19 <br /> job Address <br /> ri'� City Size/Acree6ge <br /> Owner's Name <br /> -r�NV� Phone � �^ 6SZ <br /> i <br /> ontract0 "' Address License No. 'Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME 77 DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ w SYSTEM RE AIR L1 OTHER ❑ Monitoring 41e11 CZ <br /> DISTANCE TO NEAREST: SEPTIC TANK " SEW LINES DISPOSAL FLD, PROP, LINE <br /> FOUNDATION AGRICUL -URE-W£ OTHER WELL PITS/SUMPS <br /> r # <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ .Manteca Well Excavation - Dia. of Well Casing <br /> f'7 Domestic/Private Cl Gravel Packs n•Tracy Type of sin 'L �! � <br /> g 90N� I,T�f. <br /> I') Public f'1 Other n'Deha Dept AL .r <br /> I i Irrigation — Approx. Depth I I Eastern Surface Se I — <br /> Repair Work Done U Type of Pump _ •P, on i <br /> Well Destruction ❑ Well Diameter �" Sealing Material f, <br /> Depth Fillettterial.i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIRIADDITION i I DESTRUCTION I I iNo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve;. Residence Commercial— Other <br /> Number of living units: _L_ Number ck�edroomst) f <br /> Character of snit to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg L— 'Capacity OD No. Compartments , <br /> PKG. TREATMENT PLT. 0 �r �.t� f Method of Disposal � <br /> Distance.to nearest: Well Foundation Property Line t`jnJ <br /> LEACHING, LINE k< Na. $ Length of lines -t �SS y Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation 30 Property Lyne <br /> +SEEPAGE PITS 11 Depth f Size _ Number <br /> SUMPS LI Distance to nearest: Well- Foundation. Property line <br /> DISPOSAL PONDS ❑ <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 certifier; 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 subcontracting signature <br /> canif ies 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 Californla." <br /> The appliartt must tail fruired inspections. Complete drawing on reverse side. <br /> Signed X ' -- Title: Date:FOR DEPARTMENT USE ONLY r <br /> rlAti.- _- <br /> Application Accepted by & -•- — <br /> Data Ar <br /> i <br /> Plt r r t Icy Ion by Data Final In pectin by <br /> ss��� <br /> T� Ef a2�'Jf'��1J Ct/ �� r.Gs7!C���✓[' /��tJ•�C��- f++�cC��ps6P%C�-C��r��-T'/J� <br /> Ad hia 1'Cam nt : <br /> Applicant - Return ail copies tv: San Joaquin Cvun y Public Health Services �- <br /> Environmenta3 Nealth permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE EI[ H-tep t Oz AMOUNT DUE AMOVNT REWTTED C.K RECEIVED BY DATE PERMI1'140. <br /> INFO CASH <br /> ILA <br /> . EH 13,20IREV.1�NtSl O <br /> EH ti•Za <br /> E , <br />