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APPLICATION <br /> SAN JUAQUIN COUNTY PUBLIC HEALTH S. Z ICES <br /> =�- <br /> ENV IBOriItTsNTAL .HEALTH D IV I S-ION <br /> 445 N SAN JOAQUIN, 'PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA, 95201 <br /> PF29IT-EXPIRES 1 YEAR FROY DATE ISSUED <br /> (Complete in Triplicate) <br /> Joaquin County for a permit to construct and/or install the vork herein described. This <br /> Application is hereby made-to San <br /> application is made in compliance with San Joaquin County Ordinance lo. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> Ll�.Z.tJj.4 L.D Lot Size/Acreage k <br /> Job Address (}�� <br /> Pho <br /> �sai Address ��`` 4 ne <br /> Owner's Na $� <br /> me ,�� Ad _ <br /> Contractor <br /> -��•� [�?�ct.r.e;� Address `•0-A&V " ` "� license No.&YAr—PhD y� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ Out of Service Well O <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> PUMP INSTALLATION ❑ �&. '&'Z.Wa <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIB;[;„ <br /> C] Industrial O Open Bottom ❑ Manteca Dia. of WeN Excavation._ `f' Ois. of WON Casing <br /> n Oomestic/Private ❑ Grawl Pse; ❑ Tracy Type of Casing Specifications <br /> I'1 Public n Other fl Delta Depth of Grout Seal Type of Grou <br /> I 1 Irrigation _Approx. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done O Type of Pump H.P. State Work Dan <br /> C3 Woo Diameter Sealing Material i Depth - <br /> 0749Z uctlon V Depth ,),S f— [,� Filler Material i Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIRJADOITION 1 I DESTRUCTION I I (availableNo soplic systempermitted if public sewer is <br /> within 200 feet.) <br /> Installation will serve: Residence_ Conxtwrcial— Other <br /> Number of living units: Number of bedrooms <br /> Character of sod to a depth of 3 feet: Wats table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compomrants <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest; we* Foundation Property Lim <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/sits <br /> FILTER BED ❑ Distance to nearest: WeN Foundation Property Line <br /> SEEPAGE PITS I I Depth His• Number <br /> SUMPS LI Distance to newest: Wel Foundation Property I." <br /> DISPOSAL PONOS O <br /> I hereby certify that I how prepsred this application and that the work will be done in accordance with San Joaquin county ordinances. state Iaws. and <br /> rotas and regulations of the Sat Joaquin County <br /> Hone owor licensed agentu's signst i certifies tin folowing: "I comfy that in the perfonnsms of the work for which this permit is issued. 1 shall <br /> owner not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California."Cormaetoes hiring or sub•contrilimv signature <br /> Corti We the t sa <br /> :"1 certify that in the pwfwn ws of the work for which this permit is"sod.I shall employ parsons subject to workmen's compen - <br /> tion lora California." ` <br /> The cal for Complete drawing on <br /> Signed TitN: _ Date: <br /> FOR DEPARTMENT USE ONLY !� <br /> Application Accepted by !221✓ c Oat* v{� -3 Area ` r� <br /> Ph or Grout Inspection by /r/ �G� Da u FinalInspection by p T <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services V <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'aro. <br /> INFO <br /> . E�,��lane►.�,�sr q m=- $ a� 45 <br /> Er'b� <br />