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ApPL i°CA'TI <br /> SAN JOAQU IN COUNTY PUBLIC HEALTH SERV i CES <br />' ENVIRONMENTAL HEALTH DIVISION , 'w ` <br /> rt :' X445 N SAN JOAQUIN, PHONE.(209)463420' �r <br /> P O BOX 2009:, TSTOCKTON, CA 9520I <br /> i3 p y pY� fes` <br /> ' PERM-IT EXPIRES YEAR FROM DATE ISSiTID ,p - "`• 1 <br /> (,Complete in Triplicate) <br /> .. <br /> Application,is hereby made,to San Joaquin County fora permit to eonetru54 nand install the vont h- n ascribed. This <br /> application fa made in compliance with San Joaquin County Ordinance,No. 549 and 1862 end the es-and Regulations of San <br /> Joaquin County Publ1c Health Services <br /> `Aiff - <br /> City Lot Size/Acreage CJ. <br /> ob Address ' n" <br /> _Addree ss- r QPhone <br /> Owner's Name <br /> KC.0 <br /> ntracter' D+ddtessP - icense No. PhonePE OF WELL/PUMP. NEW WELL C] WELL REPLACEMENT E71, DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER ❑ MonitoryWell C1 <br /> SEWER LINES DISPOSAL FLD. PROP. LINE " <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL PITS/SUMPS OTHER WELL "" ,`� f� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ✓' ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing -- <br /> C�Industrial' Specifications•.-£ <br /> Type of Casing_ <br /> fa Domestic/Private ❑ Gravel Pack L7 Tracy Depth of Grout Seale Type-of G ul� <br /> I'l Public f l`Olher fl Delta <br /> - A rox. Depth 11 Eastern Surface Soul installed by _ <br /> I I Irrigation pp , <br /> State Work Done <br /> Repair Work Done 0 Type of PumP _. <br /> • ' P. <br /> Sealing Material & Depth <br /> Well Destruction D Well Diameter Filler Materia"1&­VaVt'h­� <br /> Depth � "' <br /> permit <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I R PAIR/ADDITION 1 I DESTRUCTION 1 I '(No septic system 'il p6lilic rower is <br /> available within 2003est.1 p , <br /> Installation will serve: Residence Commercial Other ,- <br />'� Number of living units: Number of bedrooms * <br /> Water table depth ,Y A <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> p <br /> SEPTIC TANK T YM/Mfg Method of Disposal <br />} PKG, TREATMENT PLT. M1 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS l I Depth _—Size Number <br /> Ll Distance to-nearest...­-Well Foundation Property Line " ti! <br /> SUMPS , <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, and <br /> rules and regulations of the San Joaquin County <br /> i Horne owner or licensed agent's signature certifies the following: "l 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 /> I <br /> certifies the following: "I certify that in She 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 must for tl req d inspections. Complete-drawing on reverse side. <br /> �GP . fr <br /> Title: <br /> Date: <br /> ign <br /> EPARTMENT USE ONLY r <br /> Application Accepted by <br /> re <br /> Date—"a <br /> Date Final Inspection by Tt ,R� ate <br /> Olt or GrouOnspection by1-1 <br /> m �2 r / a t <br /> Additional Coments: <br /> Applicant~- Return all copies to: San Joaquin County Public Health Se-v�s <br /> % Environmental Health Permit/Services ti r <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> ,1 <br /> CKPERMIT'NO. <br /> M1 , FEE AMOUNT DUE AMOUNT REMITTED ECEIVED BY DA <br /> INFO <br /> '"`P•a EMA3-Z4 IREV.+ <br /> -SEH 14.2e <br />