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APPLICATION <br /> SAN JUAQUIN COUNTY PUBLIC HEALTH SERVICES 1`x'417 <br /> ENVIRONMENTAL IIEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009 , STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATED_ <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 wade in coapliance with San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San <br /> Joaquin County Puhlic Health Services. <br /> Job Address L/ :l ZI, Lot Size/Acrrage .149a <br /> Owner's Name "/4 ,,SC1�,�r.Z Address Phone ! <br /> __. <br /> Prone <br /> Contractor Li Address : y11/ Al, 5 1i(+�x _License No.d� 7 <br /> _ � _ <br /> TYPE OF WELL/PUMP NEW WELL O WELL REPLACEMENT Fl DESTRUCTION -1 Out of Service Well D <br /> PUMP INSTALLATION D SYSTEM REPAIR D OTHER :1 Monitoring Well <br /> DISTANCE TO NEAREST; SEPTIC TANK _ SEWER LINES .— DISPOSAL FLO. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER VVELI PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> R Industrial O Open Bottom C Manteca Dia. of Well Excavation Drs. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack CJ Tracy Type of Casmg__ Specifications <br /> I'l Public :11 Other I 1 Delta Depth of Grout Sell Type of Grout <br /> I I lmli)al on __ Aptxox. Depth I I Easter, Surface Setil Installed by <br /> Repair Work Done U Type of Pump H.P _ Stats Work Done <br /> Well Destruction O Well Oiamerer Se.ling Material a Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITinfkl DESTRUCTION I I [No septic system permitted if publrC sewer is <br /> available within 200 teet.l <br /> Installation will serve: Residence X Commercial _ Gther <br /> Number of Hying units: / Number of bedrooms <br /> Character of soil to a depth of 3 feet: , ��__ ---Water table depth ' <br /> SEPTIC TANK O`X tS>✓ O Type/Mfg Capacity � No. Compartments <br /> P}G- TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well __ Foundation_ Property Lina <br /> LEACHING LINE No. b Length of lines I�� Total length/size. <br /> FILTER BED O Distance to nearest: Well Founoanon d%"_ Property Lina S <br /> SEEPAGE PITS Depth Size Lo _ Number TLy!' <br /> SUMPS LI Distance to nearest: Wel3Foundauon �5• _ Property Line S <br /> DISPOSAL PONDS ❑ <br /> I hereby comity 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 /> Horne owner or licensed agent's sig,isture certifies the folowing: "I certify that in the performance of the work for which this permit is issued, I shalt not <br /> employ any person in such manna:as to become subject to workman's compensation Laws of California." Contracto!'s hiring or sub-contracting signature <br /> certifies the following: "I c*rtify that in the performonce of the work for which this porrmt is isauad, I shall employ persons subject to workman's compensa- <br /> rion laws o} C#I nia." <br /> The aped ust fc811 for.alla In"C I o. Complete drawing on reverse side. <br /> Sign �GJ Data: .�� <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Application Accepted by IAI Date _ f Area f <br /> ±i r Grout !napaction by Date[Q - 3 Final Inspection by Date <br /> Additionii Comments - <br /> Applir:.ant - Return all copies to: San Joaquin County Public Health Services <br /> hnviroestental Health Permit/Services <br /> 445 N San Joaquin, P O Hox 2009, Stkn, CA 95201000I –�J <br /> INFO FEE AMOUNT DUE AMOUNT REMrTTED Z H RECEIVED BY DATE �Y )) PERMIT NO <br /> rEm 13.24 H 14-m lAty.Tine l' %- =("' l _??5r`� LL'M 10) J�1? <br />