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APPLICATION <br /> —' SAN- JOAQUIN COUNTY PUBLIC HEALTH ;SERvl S--3 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)48' <br /> ] P 0 BOX 2009, STOCKTON, CA 9 <br /> PERMIT EXPIRES 1 YEAR FROM DATEI ISSUED I F <br /> (Complete in Triplicate) f r <br /> Application is hereby made to Sam Joaquin County for a permit to construct and/or install the work herein describ s <br /> application is made in compliance vith San Joaquin County Ordinance No. 519 and 1$52 and the Rules and Regulations of San <br /> i <br /> Joaquin County Public Health Services. <br /> Job Address 6_36 City Lot Size/Acreage <br /> , <br /> f Owner's Name Address �� 3 '- Phone <br /> [ b. Contractor Address 2 ,4rzicense No .1� ,�''�^ r Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well ❑ <br /> r <br /> - PUMP INSTALLATION D SYSTEM REPAIR C1OTHER ❑ Monitoring well Uf, <br /> DISTANCE TO-NEAREST. SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP, LINE <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> d <br /> Fit INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L] Industrial ❑ Open Bottom 0 Manteca Dia. of Well ExcavationRr f Well Casing <br /> it Domestic/Private Ll Gravel Pack 0 Tracy Type of-,Casing �Pt I'1 Public (_1Other nbaba Depth of Grout Seal TPI r r j�f•�lout Vi <br /> E I lrri{tatian —Approx. Depth 11 Eastern Surface Sea! Installed by .S C <br /> Repair Work Done 0 Type of Pump H,P. Q(�it <br /> X <br /> r„ Sealing Material i'Depth "„R /11IIlr,..� — <br /> Well Destruction 0 Well Diameter ., ` <br /> ' Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION X DESTRUCTION I ! (No septic system pe jT,Public sewer is <br /> available within 200 feet.) rr►Y' <br /> i Installation will serve: Residence le-11, Commercial Other <br /> Number of living.units:• Number of bedrooms <br /> A <br /> Character of soli to`a' depth of 3 feet:_._ —Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg ._' `t° P�`TC�_ Capacity- No. Compartments <br /> PKG. TREATMENT_ PLT. 0 Method of Disposal <br /> Distance to nearest: Well fv Foundation•l0 <br /> fri Property Line <br /> # _ LEACHING LINE NO..& Length of lines 45D Total length/size-- <br /> FILTER <br /> ength/size FILTER BED ❑ Distance to nearest: Well � �:Foundation �� Property Une <br /> SEEPAGE PITS 11 Depth — 1f <br /> 11 P + -, Size 'r �k1-47- )< Z 0 Number � <br /> _C SUMPS X Distance to nearest: Welt/ Foundation .Property Line F� <br /> DISPOSAL PONDS 0 - 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and.5 <br /> !F �) rules and regulations of the San Joaquin county t <br /> Home owner or licensed agent's iignature certifies the following: '9 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," Contractor's hiring or sub-contracting signature <br /> c certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion Iowa of California." <br /> : The applicant must call for II r uired inspections. Complete drawing on reverse side, , <br /> Signed X-1 Date: y ; <br /> FOR DEPARTMENT USE ONLY o <br /> Application Accepted by Date Z O l Area <br /> Pit or Grout Inspection by M Date Fina! Inspection by Dat <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, P O Box 2409, Stkn; CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT-REMITTED R CEIVED.BY DATE PERMIT No. <br /> EH t3-2 <br /> EH 14.2a 4 Ir1EV. <br />