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APPLICATION <br /> SAN juAQUIN COUNTY PUBLIC HEALTH SpAVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN i0AQUIN, PHONE (209)468-3420 �0�� <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FRO�d DATE ISSUID <br /> {Complete in Triplicate} <br /> Application is 'hereby made,ta San'Joaquin County for a permit to construct and/or insta3l the cork herein described. This <br /> I with San Joaquin County Ordinance No. 549 and 1862 and the Rules end Regulations of San <br /> application is made in compliance <br />+ Joaquin county Public Health Services. 1 9 <br /> f` e V <br /> City j Lot Size/Acreage <br /> Job Address �` <br />" Phone <br /> t �� IAddress <br /> Owner's Name // r�— <br /> /P�� 1 9EPLACEMIE <br /> c C 3 s 1- Phone7�Address License No.Ctintractor pE$TRUCTI t of Service Well G1NEW WELL D WELLIN Monitoring Well C7 <br /> TYPE OF WELL/PUM : SYSTEM REPAIR C] OTHER <br /> PUMP INSTALLATION . <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK ��— PITSISUMPS <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL <br /> � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Geeing <br /> n Bottom D Manteca Dia.�ofCasing <br /> Excavation E <br /> C7 Industrial Pe Specifications <br /> Typ_OomesticlFrivals Gravel Pack ' ❑ TracyType of Grout— <br /> ?<6 <br /> rout <br /> I'1 Public <br /> 11 Other D (1 Delta Depth of Grout Seal O <br /> 1 1 Irrigation Z�AppX-. Depth I I Eastern Surface Seal Installed by <br /> f H.P. State ork Done r <br /> Repair Work Done U Type of Pump _ ., Sealing Material & Depth T� <br /> Well Destruction <br /> Well Diameter �-!f�Q i l` Ad 4 <br /> ' J <br /> r <br /> Depth I Filler Material 6 Depth <br /> DITlON 4 I DESTRUCTION 1 IiNO <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADavailablerif public sewer is <br /> within 21x}feet.) <br /> Installation will serve: Residence Commercial Other <br /> kNumber of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK © Type/Mfg Capasity�— <br /> ( Method of Disposal <br /> Ii PKG. TREATMENT PLT. <br /> Distance to nearest: Wel! Foundation Property Line_- -- <br /> LEACHING LINE ❑ No. & Length at lines <br /> Total length/size <br /> FILTER BED L'] Distance to nearest: Well <br /> Foundation Property Line -- <br /> SEEPAGE PITS 11 Depth Size Number <br /> I SUMPS L1 Distance to nearest: Wel Foundation Property Line <br /> kDISPOSAL PONDS D <br /> I rk will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the wo <br /> r rules and regulations of the San Joaquin County <br /> i Home owner or licensed agent's signature cettifies the following: "I 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 /> 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 Califora," <br /> L The applicant mu c for in ctions. Co ta'drawing on reverse sid . <br /> Signed X <br /> Title: Z�Mlr Date: <br /> ", <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by !a L <br /> Date <br /> Pita rou Inspection by Date Final lnsp tion by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Heal Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> C <br /> EE tC RECEIVED BY <br /> FDATE PERMIT N0. <br /> IF O AMOUNT DUE AMOUNT REMITTED LASH <br /> r <br /> . EH 13-24(REV.I/n sl 3..f L� ,Q CA 2 (� <br /> EH 11-76 <br /> f 3Y- 00 T <br />