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r <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> vork <br /> in <br /> Application is <br /> is hherenlnm�P��� Joaquin <br /> th County <br /> ou quinoCounr a tyrOrdinancemit to nNoru5k9ct aendo1862Hand the tall eRules and eRegulations dof Sans <br /> application Joaquin County Public Health Services. fsz3,t' <br /> City Lot Size/Acreage-- r <br /> Job Address r <br /> r 1 Phone <br /> Address <br /> Owner's Name <br /> Address License No <br /> Contract or LLREPLACEMENT Cl a DESTRUCTION ❑ Out of Service Well G1 <br /> TYPE OF WELLIPUMP: NE WELL ❑ � ❑ Monitoring Well �� <br /> PUMP INSTALLATION © SYSTEM REPAIR { OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD, PROP. LINE <br /> PITSISUMPS =� r�`, <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE 44fi Dia. of Well Casing <br /> ❑ Open Bottom 0 Manteca Dia, of Well Excavation <br /> Cl Industrial _` Specifications <br /> ❑ Tracy Type of Casing_ <br /> pomestic/Private ❑ Gravel Pack Depth of Grout Seal Type of Grout <br /> 1 Public 1-1 Other 11 Delta r � <br />_ S rfaee Seal Installed by <br /> I I Irrigation — Approx. Depth I I Eastern <br /> H P > �.... State Work Done — <br /> Repair Work Done L7 Type of Pump Sealing Material & Depth R�, <br /> Well Destruction ❑ Well Diameter <br /> Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTL <br /> ALATION i I REPAIWADDITION I I AESTRUCTION I 1 available within 200 feet.l <br /> septic system permitted if public sewer is p ti <br /> ava <br /> Commercial _ Other <br /> Installation will serve: Residence ;.t <br /> Number of living units: Number of bedrooms , Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments _ <br /> Capacity <br /> © Type/Mfg <br /> SEPTIC TANK Method of Disposal t\ <br /> PKG. TREATMENT PLT. 0 Property Line <br /> Distance to nearest: Well Foundation t <br /> . r <br /> Total length/size <br /> LEACHING LINE 0 No. &,Lengthh off lines Foundation Property Lina <br /> FILTER BED n1 Distance to nearest: Well ¢ <br /> SEEPAGE PITS Il Depth <br /> r Size Number <br /> SUMPS L1 Distance to nearest: Well <br /> Foundation E ;Property Lina <br /> t I <br /> 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, an <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the foliowin : "I certify that in the performance ofthework for which this permit is issued, I shall not <br /> employ any person in such manneras to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: 1 certify that in the performance of the work for,which this permit is issued, i ah!II employ parsons subject to workman's compensa <br /> " <br /> tion laws of California." s , <br /> The applicant must call fo all required iinspections-Complete drawing on reverse side. t <br /> Title:�" <br /> Date: <br /> Signed <br /> F R DEPARTMENT USE�ONLY r <br /> Date <br /> real <br /> Accepted by <br /> Pit or Grout Inspection by <br /> Date FinalInspectionby ly' Date-=L---t <br /> Additional Comments: <br /> -- -r <br /> Applicant-=Return all copies to `""Sarv•-Joaquin...County-Public-Health Services <br /> Environmental Health Permit/Services <br /> Ir 445 N San Joaquin, P O.Box 2009, Stkn, CA 95201 <br /> CKRECEIVED t3Y DATE PERMIT'NO. <br /> FEE AMOUNT OUE AMOUNT REMITTED CASH <br /> INFO <br /> . EH 13.24 tR£V.i INS I <br /> EH 14.25 <br />