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i f <br /> APPLICATION <br /> SAN YJJ,0,9I'N COUNTY PUBLIC HEALTH ulmlL'V'ICES <br /> SVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT SPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in :Triplicate) <br /> Application is hereby made to San Joaqu_- -qty for a permlt to-construct and/or install the work berein described. This <br /> application is made in compliance with Sa-- =caquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> F �/ S <br /> Jeb Address /Z No '"'A'Il Aj ,A� citySr�K�J 1.ot gSize/Acreage �• <br /> Owner's Name `^�10d ��C T� Address 1IQy568 <br /> � � j,:a ! Phone`x� � <br /> 3233 Fti-ecx.4tx> ST !� <br /> Contraclar 1il3[ Okn/l�T Adams n License No. C PhanL�7l6 38~77-7 <br /> TYPE OF WELL/PUMP: NEW WELL-A WELL REPLACEMENT C_ DESTRUCTION❑ Out of Service Wei-1 ❑ <br /> PUMP INSTALLATICN ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Tv <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excravavti,�n IJ44 Dia. of Well Casing <br /> Oomesuc/(nva ❑ Gravel Pack = Tracy Type of Casing _,_,_`7L A. HCl Specifications <br /> f'I Public )el Other 54WO PAC4 X 0eft6-CC1*t1,3 Depth of Grout Seal 15B E' Type of Grout Akt-r <br /> I i Irrigation —Approx. Depth =astern Surface Seat Installed by .7 t <br /> Repair Work Done U Type of Pump H.P. " Slate Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Ilaurial i Depth <br /> ,I Depth Filler Material 5 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-': : REPAIR/AODITION I I' DESTRUCTION I I (No septic system permitted if public sewer is <br /> 1I available within 200 feet.) <br /> Installation will serve: Residence_ Comma�_&1_ Othar C <br /> Number of living units: Number of bac:-_Qms <br /> Character of soil to a depth of 3 feet: Water table depth {' <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to neares-- Well Foundation Property Line <br /> LEACHING LINE Q No. 8 Length of iirtes Total length/size <br /> FILTER BED ❑ Distance to neares-- Well Foundation Property Line <br /> i <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearer` Weil Foundation Property U__ <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this applicabort 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 Tai 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 aced to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the pertormancs of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." A� <br /> The applicant t call for all required inspections- Complete drawing on reverse side Sic- >C ,��� <br /> Signed Title: Date ` <br /> OR DEPARTMENT USE ONLY r <br /> Applica�ti n ccepted by C-��(.�,•�_/ItC�L - Date Area <br /> Pit or Grout Inspection by bora <br /> Final Inspection by Date <br /> Additional Comments: ��� bora - vj y ' <br /> I — _)EAZqaE <br /> Applicant - Return all copies to: Sab Joaquin County Public.Health Services <br /> ?:Tiroamental Health Permit/Services <br /> ­5 Y San Joaquin, P O-Sox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE Ar+:L!rT REMITTED CK t RECEIVED BY DATE PERMIT,No. <br /> INFO <br /> CASH <br /> C�7 <br /> • iH 113-21 tREV.;,MSI $ f 1� J - Kl hi• ✓��`�� I <br /> EH 74.76 11 _ <br />