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Page 1 of 1 <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH <br /> ENVIRONMENTAL HEALTH DIVIS7 <br /> 445 N SAN JOAQUIN , PHONE (209)4 <br /> P 0 BOX 2009 , STOCKTON , CA 9 <br /> _PERMIT E%PIRES 1 YAR FROM DATE <br /> ( Complete in Triplicate ) <br /> Application in hereby made to San Joaquin county for a permit to construct and/or <br /> application is made In compliance with San Joaquin County Ordinance No. 549 and if <br /> Joaquin County Public Health Services. <br /> Job Address' City <br /> Owner's Name --y�-(.r7 / dress <br /> Contractor S er <br /> TYPE OF WEL / NEW WELL WELL REPLACEMENT rl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DtSPOSi <br /> FOUNDATION AGRICULTURE WELL OTHER <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA' <br /> 1� Industrial O Open Bottom 0 Manteca Dia. of Well Excavation _ <br /> I i Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> 1'! Public 1-1 Other I-1 Delta Depth of Grout Seal <br /> I i Itnuation __ Approx. Depth I I Eastern Surface Soul Installed by _ <br /> Repair Work Done U Type of Pump H.P. ____ State y <br /> Well Destruction G Well Diameter Sealing Material Z Depth <br /> Depth /"Filler Material i Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION IT J REPAIR/ADDITION l DESTRUCTION 1 1 1 <br /> Installation will serve: Residence _ Commercial = Other _ : C,pi-a11P hiA <br /> Number of living units: -4— Number of bedrooms <br /> Character of soil to a depth of 3 feet: y _ <br /> SEPTIC TANK ❑ Type/Mfg '.`�l Capacity / E <br /> PKG. TREATMENT PLT. ❑ ffJJ�� <br /> Distance to nearest: Well Foundation . 7p <br /> LEACHING LINE Cl No. 8 Length of lines ---- Total len., <br /> FILTER BED Cl l Distance to nearest: Well Founaat.on F <br /> SEEPAGE PITS 11 Depth Size N ber <br /> SUMPS LI Distance to nearest: Well Foundation _.A_. P <br /> DISPOSAL PONDS Cl <br /> I herebv eftnifv that I heve nrnnarntl this annlicalinn and that thn wnri, will ha Anna in Arrnrrianra wit <br /> file://C:\Documents and Settings\mescotto\Local Settings\Temp\DMCI\DOD\I JPG 8/22/2012 <br />