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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> T P 0 BOR 2009, STOCKTON, CA 95201 <br /> PFROM DATR ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby <br /> made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is sods in compliance with Ban Joaquin County Ordinance NO. 51+9 and 1862 orad the Rules and Regulations of <br /> Sen <br /> Joaquin County public Health Services. Lot Size/Acreage <br /> Job Address <br /> Ptfane <br /> Address <br /> Owner's Name / <br /> �j �rtrurlS �� License No. Phon <br /> Address t of Service Well <br /> Contractor WELL REPLACEMENT ("1 DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> SEWER LINES .�----- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION �. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> n Industrial O Open Bottom ❑ Manteca Dia of Well Excavation Specifications - <br /> Type of Casing- <br /> 171 <br /> asing_ <br /> t 1 Domestic/Private Q Gravel Pack El Tracy Depth of Grout Seal Type of Grout <br /> I"1 Pyritic n Other fl Datta <br /> "tion <br /> —Approx. Depth I Eastern Su ce Seal Installed by / <br /> _/ of Pump N.P. State Work Done <br /> Repair Work Oona i{Y TYPe Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter Filler Material i Depth Q <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I t aNaiiabb'wdhin 200 feet.) if public sewer is Q <br /> Installation wig serve: Residence— Commercial_ Other V% <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soli to a depth of 3 feet: No. <br /> SEPTIC TANK C3Type/Mfg Capacity <br /> Methoe <br /> PKG. TREATMENT PLT. D <br /> Distance to nearest: Well FoundationProperty L• ----����� <br /> A;1f; -- <br /> Total length/size 1 I <br /> LEACHING LINE ❑ No. 8 Length of tines Pro t —RWC�S <br /> FILTER BED Cl Distance to nearest: Well Foundation � �o T EAL11'.��VIS{pN <br /> ULM- <br /> SEEPAGE PITS I I Depth Sue Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> ork will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the w <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature i 9nifiss the following: "I certify that in the performance California."the work for which this permit is issued, I shag not <br /> employ any per i uch manner as to baso wb�ect to workmen's comps sat ion laws of CrnContractor's hiring or sub contracting signature <br /> certifies the foll ."1 c that in the or nce of the work for which is pe mit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of . O <br /> The apph call i 4WI-1. omplets drawing on ve s / <br /> Signed X <br /> Title: Date: b `� <br /> FOR DEPARTMENT USE ONL <br /> Application Accepted by <br /> Data � Q� Area <br /> Ph or Grout Inspection by Date Final Inspection by Date � Z <br /> Additional Comments: _ <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, VQ Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO ZI <br /> EN 13.24 IREV,i K 51 e[� O [L' <br /> EN 14-M <br />