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r~$ APPLICATION <br /> In <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 I <br /> PERMIT EgPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> a eoaquin ..ounty for a permit to construct and/or install the vork herald described. This <br /> Application relry tttade to San <br /> rapplication is made in compliance vith Sac Joaquin County Ordinance No. 5L9 and iE02 and the Rules and Regulations of San <br /> I Joaquin County Public Health Services. t��/`� <br /> AOI ������r C�itr ti Lat Size/Acreage <br /> .lob Address `� <br /> � ��;'f.`'_• Phone ��•� !f <br /> Address' <br /> owner's Name <br /> phone r w✓'��� <br /> Contractor <br /> r Address � v — License No.,��� <br /> TYPE OF WEL !PUMP: NEW WELL 0 WELL RE ACEMENT M DESTRUCTION �} Out of Service We11 Ll <br /> M <br /> ,G SYSTEM <br /> _REPAIR ❑ 07yER u &t't'�onitoring Well ❑ <br /> PUMP INSTALLATION ee_1? ' <br /> E DISTANCE TO NEAREST: SEPTIC TANK S SEWER LINES PZ� DISPOSAL FL07 <br /> PROP. LINEY'2" _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION (r <br /> n Industrial ❑ Open Bottom G Manteca Dia. of Well Excavation, !' Dia. of Well Casing ` <br /> E Type of Casing_ Specifications <br /> F (�.1 Domestic/ Cl Gravel Pack � Tracy T dt Grant <br /> i'I Public f_1 Other Fl Delta Depth of Grout Seat rF� J <br /> i I Irrigation Approx. i Eastern Surface Setif Installed by t / <br /> Pp Depth p , <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Sealing Material i Depth <br /> Well Destruction ❑ well Diameter Filler Material ti Depth <br /> Depen i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I I [No septic system permitted if public sewer is <br /> available within 200 (eat.) <br /> Installation will serve: Residence — Commercisl_ Otlier <br /> Number of living units: vrT+ f <br /> Character of soil to a depth a � Water table depth�.. <br /> SEPTIC TANK © T /Mfg 4 . C ity No. Compartments <br /> i hdf <br /> PKG. TREATMENT PLT.❑ i�t3fmit May halia 8;Cpire Method of Disposal ( i <br /> Distance <br /> {� Prcperly Line <br /> oPJm <br /> LEACHING LINE ❑ No. & gih011it Total length/sire <br /> FILTER BED n Distance to nearest: Watt. Foundation Property Line <br /> R . SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lino <br /> DISPOSAL PONDS ❑ <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 <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following; "t certify that in the performance of the work for which this permit is issued. I shall not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California."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, I shall employ persons subject to workman's compensa- <br /> tion laws of C rrtta... �f&/J <br /> The applicant call f all requir in t' n Coale dtitle: <br /> mg on reverse side. CL��%���C'� <br /> f Data: <br /> l , Signed <br /> FOR EP TMENT USE ONLY <br /> r �C <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout IneWlion by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> 1 Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT OuE AMOUNT REMITTED RECEIVED By DAT PERMIT No. <br /> INFO � D <br /> . EM 13.24IAEv,rarer r /� ��T-- �4.a/ +�� �,��,.,, R . - /� <br />