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C,iy."rsi'�,r �,;r!�", ��a'� <br /> FNV1P%Offlff.NTAL aEALTH -DIVISION <br /> �AJM JOAQUIN COUNTY PUBLIC RRA. Th SERV-0 E <br /> 0 BOX 2009 , STOCKTON , CA. 95201 71 <br /> (209 ) 468-3447 1.2 <br /> EAVlk,ONMEN[AL HEV <br /> 2BUIT EUIRES 1 YEAR PROM DATE 1-5 5�--h h Is i'r lRo" - , <br /> (Complete to Triplicate) I I� IYl I �"1�7 %.,LO <br /> Application Is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in C=Wli&nce with Sen Joaquin County Ordinance No. 549 and 1862 and the Rules e-nd Regulations of San <br /> Joaquin County Public Health Seryices, <br /> Job Address <br /> - -n City 11 Lot. Size/Acreage <br /> 7 <br /> Owner's Name [ Address Phone <br /> Contract Addre s s ticerse N Phone <br /> TYPE OF WELL/PUMP. NEW WELL C WELL REPLACEMENT Et DESTRUCTION UOut of Service Well 0 <br /> PUMP INSTALLATION R_ SYSTEM REPAIR 31--- OTHER 2 Monitoring Well C, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ DISPOSAL FLD,_ PROP. LINE — <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL—, PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ci Ind h#I 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omes. <br /> iic/Private 0 Gravel Pack C Tracy Type of Casing Specification <br /> Public Cl Other C Delta Depth of Grout Seal Type of Grout <br /> 0 Irfluatton Approx. Depth C1 Eastern if Surface Seal Installed by <br /> Repair Work Done <br /> T�y of Pump A-6— H.P. I. � State Work Done --I- <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK- NEW INSTALLATION.0 REPAIR/ADDiTION Cl DESTRUCTION 1:1 (No septic system permitted if public sewer is <br /> available within 200 feel.1 <br /> Installation ii-All serve: Resident:. — Commercial — Other ? <br /> Number of living units: — Number of bedrooms <br /> Character of &oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. L7. Method of Disposal <br /> Distance to nearest: Well Foundation — Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to neerev: Wei! Foundation__ Property Lina <br /> SEEPAGE PITS 11 Depth —Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature canifies 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 taws of California." Contractor's hiring of sub-contracting signature <br /> certifies the following: "I certify that in the perlofmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• <br /> tion laws of California." <br /> The applicant must_c* for all required insp#ctions. Complete drawing averse side. <br /> Signed X__ Titis: <br /> Date: <br /> R D PARTMENT USE ONLY <br /> 'Z Application Accepted by Date " % � I Area —1 <br /> Fii or Grout inspection by <br /> ate <br /> Date Final Inspection by %Date 7Z 1 <br /> 7-7— <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> CK Ii <br /> FEE AMOUNT DUE AMOUNT 9EMiT'TEO RECEIVED BY DATE PERMIT N <br /> INFO CASH 0 <br /> EN 13.24 iREV iT) <br /> CH <br />