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APPLICATION. <br /> SAN JOAQUIN COUNTY 'PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN,. PHONE (209)468-3420 <br /> (Iry P O 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 compliance with San Joaquin County Ordinance No. 5ho and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. } �, <br /> Job Address / J K�' ` •' City L t,si.e/Acreage <br /> Owner'd,Neme• �� V Aia E+"1L Address �1'71Yr.E Phone <br /> r Cen rat:to Address /✓�i • YI/<<-._c,y w/(icen5e rNo��t- s'Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O 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 /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done O Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material 8 Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: ,aNEW INSTALLATION 19 REPAIR/ADDITION DESTRUCTION I INo septic system permitted if public sewer is Qt <br /> available within 200 feet.) Q <br /> Installation will serve: Residence 4 Commercial_ Other <br /> Number of living units: _/__ Number of bedrooms ' <br /> yr; Character of soil to a depth of 3 feet: - AM. Water table depth <br /> SEPTIC TANK.E�U67-0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O r Method of Disposal. <br /> Distance to nearest: Well, oundation <br /> � F <br /> �:: Ptoperty Line <br /> LEACHING LINE No. & Length of lines do"_E-77, Total length/size \(4 <br /> FILTER BED ❑ Distance,.!o nearest: Well Foundation Property Line., <br /> SEEPAGE PITS Depth O�S� Siie Number <br /> SUMPS CI . Distance to nearest: Well L .Foundation ' Property tine <br /> DISPOSAL PONDS O <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 any person in such manner 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 compensa- <br /> tion laws of California." <br /> The applicant must call for all required i s 'ons. Comple, drawing on reverse side. <br /> Mile:. gTh = F Date' —�— <br /> FOR DEPARTMENT USE ONLY'° / <br /> Application Accepted byDate /y L 'f/. <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 4eGtGGt2 l " <br /> Applicant - Return all copies to: SanlJoaquin County Public Health Services <br /> Env ronmental Health Permit/Services <br /> 445 N San Joaquin, P O.Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> EH13-24 1AFV.I A 5 <br /> EH 14•ID <br />