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APPLICATION I <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N SAN JOAQUIN, PHONE (209)468-3420 <br />P O BOX 2009, STOCKTON, CA 95201 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Complete in Triplicate) <br />I <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. 549 and 1862 and the Rules andegutions of San <br />Joaquin County Public Health Services. P- , 08007 <br />Job Address t //01L/_// U ' Ic kle a2D City 6_104 lOM Lot Size/Acreage <br />7 RX,0tA S/T. PhoneOwner's Name ^, m' Address S 9 kd3 <br />Contractor Address License No. Phone <br />TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION out of Service Well <br />PUMP INSTALLATION SYSTEM REPAIR OTHER Monitoring Well 0 <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />I <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />n Industrial Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing <br />fa Domestic/Private Gravel Pack Tracy Type of Casing__ Specifications dZ <br />1'1 Public CI Other 171 Delta Depth of Grout Seal Type of Grout <br />I f Irrigation w,Approx, Depth I I Eastern Surface Seal Installed by <br />Repair Work Done U Type of Pump H.P. State Work Done — <br />Well Destruction Well Diameter Sealing Material & Depth <br />Depth Filler Material & Depth <br />A <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION X DESTRUCTION "No septic system permitted if public sewer is <br />a Mable within 200 feet.) 11// <br />Installation will serve: Residence_ Commercial_X_ Other <br />Number of living units: Number of bedrooms <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 lines Total ength/size <br />FILTER BED 10 Distance to nearest: Well v r fT Foundation Property Line ti/D°ofT J <br />I <br />SEEPAGE PITS 11 Depth Size Number I <br />SUMPS Ll Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS i <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 taws 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 California." <br />The applicant must call for all requireddinspections.Complete drawing on reverse side. <br />Signed X'/7-se4 fc Title: Date: <br />FOR DEPARTMENT USE ONLY <br />12 <br />Application Accepted by Datej Area f <br />Pit or Grout Inspection by Date Final Inspection by Date <br />Additional Comments: <br />Applicant - Return all copies to: San Joaquin County Public Health Services <br />Environmental Health Permit/Services <br />445 N San Joaquin, P O Box 2009, Stko, CA 95201 <br />IEEE <br />AMOUNT DUE AMOUNT REMITTED CA <br />it <br />RECEIVED BY DATE PERMIT*NO. <br />EH 14-26( <br />R£V.t J n 5):