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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r°ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009111 STOCKTON, CA, 95201 <br /> k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County•Public,f{ealth Services. :�..�-.�� t. <br /> � <br /> � � 1 y��L t Size/Acreage��� o � S�L�n—i9 <br /> Job Address r Cit <br /> 71Owner's Name Address d ` Phone <br /> Contract tlAddress a C r License Nall Phone 4 <br /> TYPE OF WELL PUMP: NEW WELL ❑ ELL REPLACEMENT n DESTRUCTION 0 Out of Service Well L- f <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ —OTHER C Monitoring Well C7 <br /> DISTp NCE TO NEAREST: SEPTIC TANK SEWER LI ES DISPO FLD. PROP. LINE <br /> FOUNDATION AGRICULT RE WELL ER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTA56PECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom C] Manteca Di of ell Excavation Dia. of Weil Casing <br /> f7 Domestic/Private ❑ Gravel Pack L Tracy Ty of Casing__ _ Specifications <br /> 1'I Public 1-1 Other P Delta ept, of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surfac Sedi installed by- <br /> Repair Work Done ❑ Type of Pump Stats Work Dona <br /> Well Destruction ❑ Well Diameter Sealing lfaterial Depth <br /> # Depth Filler Material A <br /> 'TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION DESTRU� t war is y� <br /> ye, avatatile wit in feet.) >.} <br /> Installation will serve: Residence_ Commercial " Other SPE T <br /> t Number of living units: 2_0= Number of bedrooms fid– <br /> Character of soil to a depth of 3 feet: `Water table depth <br /> °SEPTIC TANK ❑ Type/Mfg Capacity C19 No. Compartments 7 <br /> PKG. TREATMENT PLT, ❑ ,—f/ I Method of DisTai <br /> Distance to nearest: Well -1 [ Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines r Tyhai lenjith/sire r f <br /> FILTER BEd { C7 Distance to nearest. Weil - Foundation - S -- Property Line. <br /> SEEPAGE PITS ' II Depth Sire 3CS dumber S <br /> SUMPSf LI Distance to nearest: Well Foundation 1 Pro r ( � party Line - } <br /> t DISPOSAL PONDS ' ❑ <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 /> : <br /> yrules and regulations of the San osquin 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 laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I comity thatinthe 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 st call for 11 r uired in ions. Complete drawing on-fevepe side. <br /> Se ned i 6 <br /> g Title: Date: <br /> FOR D -USE ONLY <br /> •rw <br /> Application Accepted byDate /�,^ ! Area Z L-- TALP <br /> it or Grout Inspection by Y Date r �� Final Inspection by ~ Dats3 <br /> Additional Com�nts: <br /> Applicant' - Return all copies to: San Joaquin County Public Health Services <br /> t Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE CK <br /> INFO AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, <br /> ' s <br /> . Err1 <br /> 3•24[HSV.f <br /> EH t,-� : , 6-7-7-3 13 C . <br />