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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby mode to Sm Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is mile in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.A99�^/{/' jrn} <br /> Job Address —zii � _" City Lot Size/Ac resee f OO <br /> dress � s + ` Phone ' <br /> Owner's Name — ' D <br /> Contractor s ense No. Phone r <br /> TYPE OF W4EL NEW WELL WELL REPLACEMENT ❑ DESTRUCTION C t of Service Nell ❑ <br /> PUMP INSTALLATION C3 SYSTEM REPAIR ❑ i OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ <br /> Drs POSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL I OTHER WELL PITS/SUMPS y <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation ; Dia. of Well Casing l <br /> ❑ Domestic/Private C Gravel Pack C Tracy Type of Casing_ it. Specifications <br /> I'I Public 1:1 Other r Delta Depth of Grout Seal ` - Type of Grout <br /> Irripauon Approx. Depth I 1 Eastern Surface Seal Installed by I <br /> Repair Work Done ❑ Type of Pump N.P. —.Stare Work Done_ <br /> Sealing Material a Depth,;. ] <br /> Well Destruction ❑ Well Diameter r , <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRlApDITION I I DESTRUCTION CTION avails allo vailable 200 fee permitted i1 public tanwer is <br /> Installation will serve: Re rdenca _ Commercial= 'Other C.OA]p�4/'rS`t ' �O�" tp�J i <br /> Number of bang units: Number o/ bedrooms ' l <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg _P7 �„ i Capacity 'l9ill No. Compartments <br /> PKG. TREATMENT PLT. ❑ t ( 7 � Method of Disposal <br /> Distance to nearest: WellFoundeiton-rl� Property Line <br /> LEACHING LINE Ell No. length/size No. d Length oLlinea: g <br /> t ii-FILTER BED O Distance to nearest. " 'Well y1.Q�. Foundation i Property Line L (p <br /> SEEPAGE PITS 11 Depth Site x I1Nhyy..m��bar !Fl <br /> SUMPS If Distance to nearest:- Well Foundation Property Line ...t -+— <br /> DISPOSAL PONDS 711 - <br /> 1 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 <br /> rues andregulationsof the Sen Joaquin County r <br /> Home owner or licensed agent's signature certifies the following. 'A certify that in the peHormance of the work for which this permit is issued, I shall not. <br /> employ any person in such manner as to become SU618ctto workmen's compensation-laws 01califomis." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance'of the work for which this permit is issued. 1*hall employ persons subjecl to workman's comports <br /> tion ewe of California <br /> The applicant mu t call for all re ed in P, is a 'Complete dra on reverse side. <br /> Signed itle: Date: <br /> T-OR ARTMENT USE ONLY <br /> -4� 3 i <br /> Application Accepted <br /> Area <br /> d by y"L 4 /� �y Date � pN <br /> Pit r Grout Inspection by� r De.S Final Inapectbn by TOete F <br /> Additional Comments: <br /> Applicant - He,turn all copies to: San Joaquin County Public Health Services <br /> ., Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 952011 _ <br /> nFEEM AMOUNT REMITTED CK RECEIVED BY DATE PERMII'NO. <br /> CASHIIIEV.�reai � �_ Z-f -t3 `�3 3- 2W / <br /> 1 fN tax <br />