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APPUCATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S&#Grs <br /> ENVIRONMENTAL IiEALTH DIVIS <br /> 445 N SAN JOAQUIN, PHONE (209) 8�'3�SA <br /> P O BOX 2009, STOCKTON, CAiJ§AWu <br /> PERMIT EXPIRES 1 YEAR FROM DA �E }� s�j,6,� <br /> (Complete in Trip at ) <br /> Application is hereby made.to San Joaquin County for a permit tr' cone uet /r <br /> e ork he This <br /> application to made 1n cotcTllance with San Joaquin County Ordinance N 549 ndt�ea an s Sen <br /> Joaquin County Public Health Services. <br /> .lob Address _1]? A 3 501P __.- _- ._ 'icy _--- Lot ze/Acreage <br /> Owner's Name <br /> n` • '-• , - A cress .____ ___ � _! Phone _ <br /> Cnntfarlor ( bc�4" d/�_Address -..-_ __ �.-'/ License No. Phone 'L��_.__ .- <br /> TYPE OF WELL/PUMP NEW WELL F) WELL REPLACEMENT Fl DESTRUCTION ❑ Out of Service Well O <br /> PUMP INSTALLATION C SYSTEM REPAIR Ll OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .,_- DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1 1 Industrial ❑ Open Bottom C I Manteca Dia of Well Excavation Dia. of Well Casing <br /> fl Domestic/Private CI Gravel Pack I1 Tracy Typo of Casing_ ---_ Specifications <br /> I'I Public 11 Other I 1 Delta Depth of Grout Seal Type of Grout <br /> 11 Irrnttauon --_ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repan Work Done 0 Type of Pump WP. State Work Done <br /> Well Destruction ❑ Well DiameterSealing Material i Depth v <br /> Depth — Filler Materia i Depth <br /> 1"Y'FE OF SEPTIC WOPK: NEW INSTALL ION I I REPAIR/ADDITION DESTRUCTION I 1 INo septic system permitted if public tower is <br /> available within 200 feet.) <br /> installation will serve: Res5pce _ Commercial _-_ tI er/��, <br /> Number of living units: ✓ Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: __.___ ..___ _.-_—..__- . .._ __ Water table depth 1� <br /> SEPTIC TANK Cl Type/Mfg Capacity_ No. Compartments \v <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & len th of lines _ 0 T tal len th/size O <br /> g - -.. - k 7-------- q 9 <br /> FILTER BED Distance to nearest: Well __. t9 Founoatron n Property Line <br /> SEEPAGE PITS 11 Depth Size ._ _ J O Number <br /> SUMPS X 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 clone 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 any person in such mariner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 componsa- <br /> tion laviL.QfCalifornis.11 <br /> Th j4gplica call for all required ' ections. Complete drawing on reverse side. <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by _L _ Date I2 real /'09 <br /> Pit or Grout Inspection by — Date Final Inspection <br /> dditional Comments: <br /> Apl`lirrr.nt - Return all copies to: San Jonquin County public Health Services <br /> Environmental Health permit/Services <br /> 445 N San Joaquin, O Box 2009, Stkn, CA 95201 <br /> FEE <br /> `2, INFO AMOUNT DUE AMOUNT nFMITTED CASH RECEIVED BY DATE PERMIT NO, <br />