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- APPLICATION <br /> SAN dOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION T Zf <br /> C445NOXSBOJ2009, STOCKTON, CAPHONE )95201420 <br /> N� <br /> P <br /> PERMIT EgpIRES 1 YEAR FROM DATE ISSUID <br /> (Complete in Triplicate) S\I� <br /> Application is hereby meed <br /> e to San Joaquin County for s permit to construct and/or install the work herein described. Sans <br /> application is made 1n compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations <br /> Joaquin County Public Health Services. <br /> 11"A 4r 3 i s Lot Size/Acreage <br /> Job Address -,�/ ve a467-3- 3-5-d <br /> r j - + Phone <br /> r� I Address <br /> Owner's Name V <br /> License No. Phone <br /> Address���--- DESTRUCTION ❑ Out of Service Well ❑ <br /> Contractor WELL REPLACEMENT n Well C3 <br /> NEW WELL ❑ OTHER ❑ monitoring <br /> I TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE <br /> �-- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> �— <br /> INTENDED USE TYPE OF WELL PROBLREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> Dia. of Well Excavation <br /> Cl industrial ❑ Open Bottom. 0 Manteca Specifications <br /> ❑ Gravel Pack ❑ Tracy --Type of Casing <br /> Cl Domestic I Private Type of Grout <br /> I:] Other Cl Delta Depth Grout Seal <br /> 11 Public Surface Sedl Installed by <br /> I I irrigating <br /> Approx, Depth I I Eastern H P State Work Done <br /> _� <br /> Repair Work Done 0 Type of Pump - Sealing Material & D <br /> Well Destruction ❑ Weil Diameter Filler Hateria Depth <br /> Depth <br /> a ilable within 200 lost.i <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION ! 1 REPAtR1ADD1Tll�M 1 DESTRUCTION IN I septic system permitted'il public sewer is <br /> Inata n will serve: Residence Commercial, Other <br /> Number of liw nits: Number of bedrooms - Water table depth <br /> Character of soil to a th of 3 feet: Cap No, Compartments <br /> SEPTIC TANK dI /Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to near Well <br /> Total length/size <br /> LEACHING LINE Ll No, 8 Length of lin Property Line <br /> FILTER BED <br /> 0 Distance to rest: Well dation ��— <br /> Size Mb or <br /> SEEPAGE PITS Depth Pre Lines-- <br /> SUMPS <br /> LI Distance to nearest: Well Foundation op <br /> DiSPO ONDS ❑ <br /> I reby certify at the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> that I have prepared this application and th <br /> rules and regulations of the San Joaquin County -1 4�_ work 10, his d. <br /> Home owner or licensed agent's signature certifies the <br /> eccito wingkmen Bcertify <br /> co that inttheion lawsoof ince miahe ContractoN slhir ng oPsub cont acermit is englsignlatu4e <br /> employ any person in such manner as to becomes I <br /> tortillas the following: "I certify that in the performance of he work for which this permit is issued, I shall employ persons subject to workman's compen <br /> sa- <br /> tion laws of California." <br /> I The applicant tali for all required inspections. Complete drawing on re <br /> 11 Title: _ ' <br /> CLI _ Date: -- <br /> / _ ,- <br /> X Signed X._.�- - f - .. � � �-EAtT USE ONLY ��r,t <br /> OR I"�+ <br /> Date Area � 2- 11 <br /> Application Accepted by Date <br /> k Date. Final Inspection by <br /> 1 Pit or Grout inspection by <br /> Additional Comments: <br /> a <br /> Applicant - Return all copies to: EnvironmentaloHealthuPermit/Servicesv Services <br /> 445 N San Joaquin, P Q Boer 2009, Stkn, CA 95201 <br /> CEIVED By DATE. PERMITNO. <br /> FEE AMOUNT DUE AMOUNT REMITTED f //I <br /> INFO - <br /> . EM 13.241r1EV.t i s+ <br /> s b �- <br /> EH 14.26 <br />