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f <br /> APPLICATION Q <br /> SAN JOAQUIN COUNTY PUBLIC HEAL l� <br /> H a� <br /> ENVIRONMENTAL HEALTH DIV # •��� <br /> 445 N SAN JOAQUIN, PHONE {20 ) . 4' <br /> P O BOX 2049, STOCKTON, C # <br /> 4 <br /> PERMIT EXPIRES I YEAR FROM D T ED <br /> (Complete in Triplica <br /> F . <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is raade'la coe'liance vith San Joaquin County Or No. 549 and 1862 Ylnd the Rules and Regulations of San <br /> Joaquin County Public�1Health.Services. <br /> City Lot Size/Acreage <br /> Job Address <br /> 11 <br /> 2 <br /> x_96 <br /> Owner's Nam �- Address 4 Phone <br /> CvnNatt r Address 1 :767 License ha. 7Z Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER C1Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation_ Dia. of Well Casing <br /> [, Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I{�hs <br /> i'1 Public 1:1 Other n Delta Depth of Grout Seal e t <br /> F I I Irrigation —Approx. Depth l I Eastern Surface Seal installed by <br /> cc iRepair Work Done 0 Type of Pump H.P. <br /> F <br /> , i State Work Dop" <br /> Well Destruction ❑ Well Diameter Sealing Material Depth rt Flli„� <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR1ADOITION I I DESTRUCTION l I 01;1 i i` r ic-sewer is <br /> within 200 feet.) <br /> Installation will serve: Residence_ Commercial.— ther <br /> r Number of living units: Number of ooms <br /> Character of soil to a depth of 3 teat: Water table depth <br /> SEPTIC TANK Type/Mfg j Capacityy No. Compartments <br /> PKG.'TREATMENT PLT. Cl ! r Method of Disposal <br /> Distance to nearest: Well Foundation <br /> + Property Line <br /> LEACHING LINE No. i Length of lines � Top(length/size � <br /> FILTER BED ❑ Distance to nearest. Well s��” f' Foundation _�l� '- Property Line � <br /> r It <br /> f SEEPAGE PITS Depth Size� Dumber l SUMPS UI Distance to nearest: Well I QO - Foundation--A Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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 /> i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature. <br /> certifies the following:­11 certify that in the performance of the work for which this permit is issued, I shallemploy parsons subject to workman's eompensa- <br /> tion laws of California." <br /> The applicant st tail for al r ire 'nspections. Complete drawing on reverse side. T <br /> Signed Title: Date: <br /> �i FOR DEPARTMENT USE ONLY <br /> C4_� <br /> Application Accepted by Date Area <br /> or Grout Inspection by -Frte=��r�-�--`�` Final Inspection by Data <br /> Additional Comments,- <br /> Applicant <br /> omments:Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/ ervices <br /> !j 445 N San Joaquin 009, Stkn, CA 95202 <br /> t r+ FEE AMpt)NT Ot1E AMOUNT REMITTED RECEIVED BY TE PERMIT'NO. <br /> INFO <br /> • EM71•yE01Ev.tiersf � — <br />