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r' APPLICATION <br /> JOA(,t N COUNTY PUBLIC HEAL H <br /> C �� ENV RONMENTAL HEALTH DIV S <br /> / . S JOAQUIN, PHONE (20 )4Q. <br /> 420 <br /> z.. P 0 B X 2009, STOCKTON, C <br /> AID <br /> � 1Li # r FI PERMIT IRES 1 YEA46 <br /> R FROM D ED <br /> F ..(Complete in Triplica e <br /> e k herein described. Thi <br /> I A ereby made.to Sen Joaquin County for a perm;t to construct a / d e n. <br /> t application is made in compliance with San Joaqu <br /> F in County Ordinance No. 51+9 an m <br /> Joaquin County Public Health Services4 t ! p <br /> Lot Size/Acreage <br /> Job Address <br /> Owner's Name <br /> Cy� �V)ddress Y,rte! / / / Phone <br /> / �G1 License tyor� Phone t � <br /> F <br /> Contractor-4,/--i--1,(/L AddressZ:FLI <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well OTHER ❑ Monitoring Well 0 ' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> r=� <br /> F] Industrial ❑ Open Bottom ED Manteca Dia, of Well Excavation <br /> Specifications <br /> [I Domestic/Private 0 Gravel Pack Type of Casing_.❑ Tracy Type of Grout � <br /> PuhliCl Other fl Delta Depth of Grout Seat <br /> � I'1 c SLJ <br /> _Approx. Depth i I Eastern Surface Seal Installed by <br /> k f ublition <br /> { of Pump H.p. State Work Done <br /> Repair Work Done U Type <br /> Sealing Material i Depth <br /> s.. Well Destruction - ❑ Well Diameter Filler Material & Depth �} <br /> Depth1 <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION 1� REPAIRIADDITfON { ! DESTRUCTION I ] availablerc system rmitted w hin 200 feet-I if public sewer <br /> is <br /> s' Installation will serve: Residence jL. Commercial_ Other <br /> Number of living units; � dumber of bedrooms <br /> 4 Water table depth r <br /> �_ Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK. ❑ Type/Mfg Capacity,� <br /> ' Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Elf IN <br /> ' <br /> � Distance to nearest: Wel! N Foundation Property Line�...� <br /> F! Total length/size <br /> LEACHING LINE I ' No. & Length of lines _ �� �- <br /> FILTER BED <br /> Distance to nearest: Well Foundation .-�— Property Line <br /> SEEPAGE BITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> MIR <br /> DISPOSAL PONDS ❑ r ces, state laws, and <br /> j t hereby certify that I have prepared this application and that the work will be done in accordance with San J_a <br /> rules and regulations of the San Joaquin County °gyp° <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the workt4 fc �t g it is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Co°i� Wr s hit?p b-�cqokman'sgompatur <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall e�NINy�UHYU I ISI C� 1V i T <br /> tion laws of California." pUBLIC II .ALTH SERVICES <br /> The applicant must call for requ ed loupe ns. Complete drawing on reverse side. eNVIRONMENTA� � {DIY"Ila <br /> F. <br /> a, Title: <br /> Data: <br /> Signed <br /> FOR DEPARTMENT USE ONLY q 4911 <br />' ^ l4 ` LArea <br /> a Application Accepted by = Date <br /> - Pit or Grout Inspection by Data -- <br /> Final Inspection by _ Q Date- r <br /> t Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental. Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE RECEIVED BY PATEPERMIT'NO.AMOUNT DtJE AMOUNT REMITTHE INFOTh <br /> EH Q-24 SREV, <br /> EH 14.26 <br />