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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION I � E�� <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 CE1V <br /> P O BOX 2009, STOCKTON$ CA 95201 APR 2 6 1993 <br /> PERMIT EgPIRES 1 YEAR FROM DATE ISSUED USAN OAQUIN COUNTY <br /> �QNM�� �� <br /> (Complete in Triplicate), ENV! HEALTH SERVIC # <br /> Application is hereby made-to San Joaquin County for a permit to construct and/or install the <br /> quin County Ordinance No. 549 and-1862 and the Rulesules and <br /> application is made is compliance with San JoaRegulation n <br /> Hi' <br /> Joaquin county Public Health servic s. Lot Size/Acreage <br /> City <br /> Job Address . <br /> Phone <br /> [ISAddress <br /> Owner's Name ,yA <br /> Contractor Address <br /> QfLU[ License Na.C�4 Phone <br /> NE WELL [� WELL REPLACEMENT DESTRUCTION1 Out of Service Weil ❑ <br /> TYPE OF WELL/PUMP: _ _ ---'�'°""'""lOTkR-❑—Monitoring-Well❑- <br /> _,."_..� .SYSTEM REPAIR <br /> PUMP INSTALLATION❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �____�— PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> FOUNDATION <br /> ELL <br /> T--- �- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUGTION SPECIfiCATEDNS Dia. of Well Casing <br /> ❑ Open Bottom 0 Manteca `Dia. of Well Excavation <br /> C-1 Industrial Specifications <br /> C7 Tracy ;Type of Casing_ <br /> Domestic/Private ❑Gravel Pack }pepth of Grout Seal Type of Grout <br /> 1 Public i`1 Other Cl Delta , <br /> �,Approx. Depth I I Eastern +Surfacel,Seal Installed by 4 <br /> I I IrriOa[ian t State Work Done /V <br /> H.P.Repair Work Done L7 Type at Pump +� $ealing`Materisl i Depth <br /> Weil Destruction ❑ Well Diameter Filler Material Depth `l <br /> Depth t r.+w ". /`r <br /> TYPE OF SEPTIC WORK: NfW INSTALLATION f REPAIR/ADDITION 11, DESTRUCTION I I �Nailable.'wthem <br /> in 200 feec 5 stery pe t.) if public sewer is <br /> 4 <br /> Installation will serve: Residence Commercial^ Other <br /> Number of living units: Number of bedrooms <br /> r Wates table depih <br /> j Character of soil to a depth of 3 feet: No. Compartments C <br /> f SEPTIC TANK. ❑ Type/Mfg T Capacity -- <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ �" ' <br /> a { Foundation <br /> } Propertt Line — m <br /> Distance to nearest: Well <br /> i.Toral lengthlsize <br /> LEACHING LINE Cl No. & Length of lines I Property Line <br /> FILTER BED [I Distance to nearest: Well Foundation <br /> i I I Depth Size Number <br /> i SEEPAGE PITS Property Line <br /> SUMPS LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sar Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County work for <br /> l not <br /> Home owner p <br /> erson <br /> licensed agent's <br /> nne gas to become subjects to wo kman'srtcompensat on lify that in the aws of Californian"Contractor'slhiring op sub-contra t nglsignature <br /> i employ h ma <br /> certifies ertify that in the performance of the work for which this perm{t is issued, i shall employ parsons subjects workman s compens <br /> y Non lawi 1 <br /> The appor all requir spection . omplatei.drawing o e ide ! <br /> Tr, �� .�... a Date: <br /> Signed i <br /> FIVEPA N Y <br /> 3 � <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date�..�— Final Inspection by Date <br /> Additional Comments: "`*k <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . fH 13-44lttEV.tines <br /> EH 11.20 !- _ <br />