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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 PAYMENT <br /> If P 0 BOX 2009, STOCKTON, CA 95201 RECEIVED <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED APR 2 S 1933 <br /> (Complete in Triplicate) SAN JOAQUIN COUNTY <br /> Application is hereby mal San Joaquin County for a permit to construct and/or ins PLIC ��� ans <br /> compliance <br /> application in made in courtpliance with San Joaquin CountyOrdinanceNo. 51+9 and 1862 an Joaquin County Public Heil ; <br /> ces. <br /> Job Address R v r <br /> City Lot Size/Acreage <br /> (i <br /> Pl, <br /> Owner's Name Address C Phone117 <br /> Contractor Address License No.Q,(O 7(of Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Dut of Service Well <br /> PUMP INSTALLATION CJ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST"SEPTIC"LANK t - SEWER`LINES _`DISPOSA•r FLD—PROP-LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> -Dia., - - ..-. <br /> C7 Industrial p Open 9ottom•�"❑ Manteca T�'�`T'Dia'of 1Neil Ezca'vation�'� "°� Dia: of'Well'Casin <br /> C} Domestic/Private ❑ Gravel Pack 1 U Tracy Type of Casing_ Specifications <br /> [1 Public C] Other A Il Delta Depth of Grout Seal Type of Grout fl <br /> Irrigation Approx. Depth I I Eastern S rface Seal Installed byr`iJ <br /> Repair Work Done U Type of Pump �!7 H,P. State Work Done V <br /> Well Destruction' ❑ Well Diameter t ` Sealing Material & Depth (� <br /> Depth `Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION ( I REPAIR/ADDITION f I DESTRUCTION I I INo septic system permitted it public sewer is <br /> ' r available within 200 feet.) <br /> a <br /> Installation will serve: Residence—.-_. Commercial_ Other L <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK r ❑ Type/Mfg = Capacity No. Compartments <br /> PKG. TREATMENT PL } <br /> � T' ❑` f € Method of Disposal <br /> Distance to nearest: Well Foundation _ Property Line rr <br /> f LEACHING LINE C1 No. & Length of tines <br /> € Taral length/size <br /> r FILTER BED ❑ Distance to nearest: Well <br /> M Foundation Property Line <br /> SEEPAGE PITS <br /> 11 Depth °"^ - Size--- Number <br /> SUMPS , L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ j <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 /> Horne owner or licensed agent's'Signature certifies the �` <br /> g g g: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any para i such manner.as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the in :!?,r"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 f Cali la." <br /> The appli t call for all requir spgction omplete drawingArerside, <br /> Si nedoTitle: a � Date:FOR PAS NLY I <br /> r� <br /> Application Accepted by Date Area �a <br /> Pit or Grout Inst r cti6.rl Date Final Inspection by Data <br /> Additional Comments:. f 1 Y <br /> Applicant;'.=�Re.turti all copies. to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> '* t 445 N San-Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE I AMOVNT REMITTED <br /> INFO SH RECEIVED 8Y DATE PERMIT'NO <br /> + EH 13.24IREV.rinse <br /> EH 14.2e <br />