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APPL I CATION <br /> TT <br /> -� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' 1 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> F, P O BOX 2009, STOCKTON, CA 95201 <br /> t PERMIT EXPIRES 1 YEAR FROM DATE ISSUID <br /> (Complete in Triplicate) <br /> Application 1s hereby made,to San Joaquin county for a permit to construct and/or install the work her in described. This <br /> application is made in compliance vith San Joaquiunty 0nance No. 549 and 1862 and the Rules an Regulations of San <br /> Joaquin Coun40'-Am'm <br /> Public Health Services. } '' �y <br /> City &*' Lot Size/Acreage <br /> JobAddress > Ir2r Address 57 4mv 46L-44,7 <br /> L Phone #=i * -nz, <br /> Owner's Namer� t «. <br /> 4 �i r 1 ttit 1 3A 1'° q Phone 72 4 <br /> Contractor f l Address License No. <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ 0 TRUCTION Out of Service Well ❑ <br /> oring Well CI ` <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR =-5A--L <br /> �/j'"OTHE. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FLD. PROP. LI <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS <br /> n Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (:1 <br /> Domestic/Private ❑ Gravel Pack El Tracy Type of Casing___ Specifications <br /> - ~ <br /> I'1 Public Cn <TYPa of Grout <br /> l Other Delta Depth of Grout Seal <br /> gation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done v Type of Pump H.P. State Work Done _ <br /> Sealing Material & Depth <br /> Well Destruction O Well Diameter <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INailabPertic wisystem <br /> thin 200 feetrtled it public sewer is <br /> Installation will serve: Residence-_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _— Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> 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 any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif nia." <br /> The applicant ed=bionsComplete drawing onside a at <br /> sidee� t� <br /> ,7j- D <br /> Signed X / Title: - '7J <br /> FOR DEPARTMENT USE ONLY <br /> Ap lication Accepted by Date Area <br /> Pit o 6Grt Inspection by <br /> Date I Inspection by rDate � ?� <br /> Ad " <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> CK 8 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> INFO <br /> . EH 13.24(REV.I A5) YV 9— <br /> EH 14.26 a <br />