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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES y <br /> ENVIRONhENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> { PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> pplication is hereby made to San Joaquin County for a <br /> f application is msae in compliance with San Joe uin Counters Ordinance t to construct <br /> ruc and/or and install <br /> 62 theRulesand described. This <br /> Joaquin County Public Health Services, q y 9 <br /> s Regulations of San <br />' Job Address <br /> T City Lot Size/Acreage <br /> Owner's Name ` <br /> Addres <br /> a t . Phone <br /> Contractor I <br /> �� fsTYPEOF WELL/PUMP: NEW y ,' License Nis Phon <br /> - - :.WELL REPLACEMENT [�_ <br /> PUMP INSTALLATION ❑ _ DESTRUCTION.0 Out_of Service Well ❑ <br /> DISTANCE r0 NEARESTrSEPTIC TANK _. SYSTEM REPAIR ❑ i OTHER ❑ Monitoring Well <br /> ----� SEWER LINES � `y DISPOSAL FLD" <br /> FOUNDATION PROP. LINE <br /> ----- AGRICULTURE WELL -OTHER WELL' , <br /> INTENDED USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> : PITS/SUMPS <br /> I Cl'Industrial EI Open Bottom —��` <br /> D Domestic/Private ❑ Manteca Dia. of Well Excavation <br /> C7 Gravel Pack ❑ Tracy Dia of Well Casing <br /> t f'1'Pubfic 1.1 Other Type of Casing_ ` <br /> C1.Delta Depth of Grout Seal f * Specifications t <br /> f I irri0ation Approx. Depth I I Eastern Type of Grout ' <br /> Repair Work Done ❑ '� 'Surface Seal installed by ° f <br /> Type of Pump <br /> H.P.t `-t <br /> Well Destruction ❑ Well Diameter Sealing Material & DepthState tilVtirk Dpne_ <br /> r <br /> Depth Filler Materiel & Depth t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION fNo septic system permit <br /> s <br /> > <br /> Installation will serve: Residence Pe ed if public sewer is <br /> Commercial available within 200 feet.! f <br /> Number of livin units; Other <br /> g. _ „Number of bedrooms ° k zti tt�q / <br /> i Charactef of 9011 to a depth of 3 feet: <br /> SEPTIC TANK <br /> ❑ TYpelMfg <br /> . Water table depth } <br /> - ty - ~'tl ' <br /> PKG. TREATMENT.PLT k[1 -., �.,. ,, Capaci �� No. Compartments <br /> p;• <br /> ance ne <br /> Method of Disposal <br /> Distto est Well _ Foundatigri 4 <br /> r<•---, -+--_ .:. , --tom_ Property Line <br /> LEACHING LINE ❑ No. & Length of lines t <br /> FILTER BED ❑ Distance to nearest: <br /> Well i Total length/size i <br /> �=_ Foundation- I r <br /> Property Lire <br /> SEEPAGE PITS <br /> 11 Depth <br /> SUMPS Number <br /> Cl Distance to nearest: ' Well I s <br /> DISPOSAL PONDS ❑ Foundations Property Line <br /> I hefsby 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 fie any Person llowinn such manner as to become subject to workman's compen9ation.iaws of California.^Contractor's hiring or sub-contracting signature i <br /> certifies the-followin i certi. that in.the.perfarmsnce of.the.work.for which.this permit is issued,-.1.shall..em Ia <br /> tion Iowa of Califomla." p y persons subject-to workman's compensa-, <br /> The applicant m st a or a requi d inspectfions. plate drawing on toverse side. <br /> Signed X s <br /> Title: ��� <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Data <br /> Pit or Grout Inspection by <br /> Date-� Final Inspection by Z <br /> ' <br /> Additional Comments.- <br /> App,,Iicant <br /> omments:Applicant - Return all copios to: San Joaquin County Public Health Services <br /> j Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT RE 1rtEO K <br /> i 11 CA RECEIVED BY ;�/ <br /> PERMIT'NO. <br /> EH 14.24(REV..1 �t J <br /> EH 14.20 <br />