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APPLICATION I <br />' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ZU -IDCtt5-5Z qr , <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br />' P 0 BOX 2009, STOCKTON, CA 95201 <br /> . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 made in cottipliance 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 44L44 A City �2pr+ Lot Size/Acreage <br /> Owner s Name Address Phone tvv L44P ' <br /> Contractor ktreIk-Jt-=rr.'t_t7r_fL. QVC, Address 726'1S 44 License No �` Phone <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well ❑ <br />' PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER Monitoring Well ❑ <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLO IP1- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL Mi36-Tb Zai c� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia of Well Excavation 1140 <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ slme.11eam Ar, t f <br /> I 1 Public C1 Other Cl Delta Depth of Grout Seal Will <br />' I I Irrrpation .,,,.Approx Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L] Type of Pump H P <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth aPbr' "tUt.lAtr <br />' Depth Filler Material i Depth -CX.— 1�S <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIRIADOITION 13 DESTRUCTION I i (No septic system permuted of public sewer is <br /> available within 200 feet 1 <br /> Installation will serve Residence_ Commercial_ Other <br /> Number of Irving units Number of bedrooms V <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 nearest Well Foundation Property Line <br /> LEACHING LINE ❑ No & Length of Imes Total length/size <br />' FILTER BED 0 Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br />' SUMPS Ll Distance to nearest Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws and <br />' rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature candies the following I certify that in the performance of the work for which this permit is issued, 1 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 compensa <br /> tion laws of Caldornla " <br />' The applicant must call for all required inspections Complete drawing on reverse side <br /> Signed X edTitle Date N 1_"'1 T � <br /> 1��/. p y FOR DEPARTMENT USE ONLY _ <br /> Application Accepted by ]moi + 6-tp ._ Date # Area • �' <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Addrimnal Comments <br /> Applicant - Return all copies to Sa Joaquin County Public Health Services <br /> Environmental Health Permit/Services O t <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 • I <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERM17 NO <br />'EH 124[REV 1/1,10rve y o� !a3 531 I9 L( <br /> 2a D43Z3U <br /> EH 14 <br />