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,- APPLICATION <br /> SAN JOAQUIN COUNTY. PUBLIC ,HEALTH-SERVICES <br /> �-- ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3. 20 �h lit / <br /> P O BOX 2009,. STOCKTON, CA 952011i V-' `f <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUID <br /> (Complete in Triplicate) <br /> Application is hereby made''to San Joaquin County for a permit to construct and/or install the vgrk herein described. This <br /> application is made in compliance with San Joaquin County Ordinance'No. 54 and 1662 and the Rules and Regulations of San <br />_ Joaquin County Public Health Services. 1 0 <br /> Job Address City' L V Lot Size/Acreage <br /> O�1, �j /�} /� {/'��� apt., ,i� )` <br /> Owner's Name L{t�V I � � .14ddress r�9 �l' �1/'�EL1Jf i� i',+ ux.' I Phone <br /> enlw &L <br /> _T <br /> COL <br /> ntraCIO Address License fNo., a3 Phon <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLA MENT [I DESTRUCTION X.Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER C3Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. I PROP LINE <br /> FOUNDATION "-"'�"`"- A"GAiCUL7URE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA; CONSTRUCTION SPECIFICATIONS S1 /J <br /> C7 industrial ❑ Open Bottom 0 Manteca Dia. of;Well Excavation =',Dia. of Well Casing 3 Y <br /> C7 Domestic/Private 0 Gravel Pack C7 Tracy Type of Casing_ w(- i 'specifications ,1 <br /> V1 Public fa Other n Delta+ r Depth of GroutSeal `TV of Grout r <br /> ti Irrigation _ Approx. Depth € I Eastern < Surface Seal Installed by pr SSur O►a Ina ' <br /> Repair Work Done 0 Type of Pump t H,P. t ��_ State Work Done I <br /> Well Destruction Well Diameter Sealing Material i Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WOR : NEW INSTALLATION I 1 REPAIRIADD€TION 11 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available 200 feat.i <br /> Installation will serve: Resid Commercial_ Other <br /> Number of living units: Nu r of bedrooms ri: ... <br /> Character of soil to a depth of 3 feet: Water table;depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compar'tr4i t:­ <br /> PKG. TREATMENT PLT. Gl ;: Method of Disposal <br /> Distance to near Well J ndation Property:,Line i <br /> LEACHING LINE Cl Length of lines otal length/sine <br /> FILTER BED Distance to nearest: Well Foundation operty Line <br /> SEEPAG S I I Depth Size !Number <br /> Distance io nearest:" `Weil` ^" Foutiitation-"""'-- Property Line <br /> DISPOSAL PONDS ❑ " �I 't j ?' a <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 an n in such manner as to become subject to workman's compensation laws of California." Contractor's hiring Or sub contracting signature <br /> certifie a follow g: "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 f s 01 Califor ie." <br /> The ap licant mus call for all r uu ins o mplete drawing o rmm�� <br /> M ..rt ) <br /> Signed X Title: "Date:" <br /> FOR DEPARTMENT USE ONLY �:J J. 9:;�I.� •� <br /> Application Accepted by Data +�'i'�' L! + Arsa �z` <br /> fD.Zr `l ` • L <br /> Pit or Grout inspection by Date y Date <br /> (� Final Inspection b '} - <br /> Additional Comments: �`'L tL5k ye, c?✓ C}Y� <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services t <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> 1FEE AMOUNT DUE AMOUNT.REMITTED CASH) RECEIVED BY GATE; PERMIT'N0.' <br /> ti <br /> EM <br /> 9.24{REV.1�>151 <br /> ,.-� ( D130v'�i <br />