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APDL 16T I ON FOR PSRId I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSPED <br /> (Complete in Triplicate) A <br /> Application is hereby made to SaaJoaquin County for a permit to construct and/or install the vork herein described. This <br /> application is a in compliancefvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County blic H ltbjSerMces. <br /> Job Address City 2tlLot Size/Acreage <br /> � f <br /> Owner's e P Na `` Ad rens Phone <br /> Co ra o �(� /Gt.f[ABre <br /> 90dZJZ4ense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ F DESTRUCTION 0 Out of Service Weii 0 <br /> r PUMP INSTALLATIO4� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 dustrial ❑ Open Bottom ID Manteca Dia- of Welt Excavation Dia. of Well Casing <br /> omeatie/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> l'1 Public 1:7 Other 1-1 Delta epth of Grout Seal Type of Grout <br /> I I iniflation —.Approx.:Oe 1 I stern r ,5u'rfaee Seal Installed by <br /> Repair Work Done U Type of Pu H.P. ( ' State Work Do <br /> Well Destruction ❑ Well Dia ter ;1::-g2 <br /> Sealing Material i Depth <br /> Depth Coy Filler Material i Depth ��,(� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public "or is <br /> ` 1 available within 200 feet.) <br /> Installation will serve: Residence--a� 't Commerciat— Other <br /> Number of living units: Number of bedrooms - �- <br /> Character of roll to a depth o�f 3 fee; r f •�` Water table depth <br /> SEPTIC TANK. O,-Typs/Mfg �`�' Capacity* �^ ~ No. Compartments <br /> PKG. TREATMENT PILT.G1 k " "f x � <br /> - �ti Method of Disposal <br /> Distance to nearer;:;..,_,,.Well--- - -.-.--.--,.Foundation aProperty Line <br /> LEACHING LINE ��Ll No. & Length of lines `7otallength/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS. i I I Depth f Size Number <br /> SUMPS J . LI Distance to rwarest: Well- v Foundation Property Line <br /> DISPOSAL PONDS.1-,'O ._' <br /> 1 hirabyAesrtify 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 Sen_Joaquin Count ) + <br /> Home owner or licensed'agent'a 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." Contractors hiring or sub-contracting signature <br /> certifies the following: "1 WON the in the performance of the work for which this permit is iss ed,I shall employ persons subject to workman's compenss- <br /> tion laws of rnia." <br /> Thea t t call to ins tions. Complete drawing on r rse sig / <br /> Title• Date: <br /> FOR DEPARTMENT USE ONLY - <br /> Application Accepted by — __ _ Date Area DL- f q� <br /> Pit or Grout Inspection byDate Final Inspection by Date <br /> Additional Comments; <br /> Applicant Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> z r 445 N San-Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO FEE AMOUNT DUE i AMOUNT REMITTED CK ECEIVED BY DATE PERMIT NO. <br /> . EM14.2 (REV.i i M 5 <br /> EH tb2e <br />