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APPLICATION 'f <br /> SAN JOAQUIN COUNTY PUBLIC HEAT,ENH�r:ls x� <br /> ENVIRONMENTAL HEALTH DIV ,r <br /> 445 N SAN JOAQUIN, PHONE (209 0 `� <br /> P O BOX 2009, STOCKTON, CA �2 <br /> PMITEXP SFRO D <br /> -UARs, (Complete in TriplicattA111 # 70 �-- <br /> Application is hereby mete to San Joaquin County for a permit to construct and/ 11�Y e vork herein described. This <br /> application is made in cotgpliance vith San Joaquin County Ordinance No. 51+9 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address LLX <br /> � City Lot. Size/Acreage <br /> KOwner s Name ■• Address s0 -fF9 Phone <br /> Contractor Address License No.D=61 Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT M DESTRUCTION ❑ Out or service Well 0 <br /> PUMP INSTALLATION © SYSTEM REPAIRV OTHER 0 Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEAITIC 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 /> 0 industrial ❑ Open Bottom p Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I I Public. Other r !171 Delta Depth of Grout Seal Type of Grout <br /> E I I ! niton <br /> rg Approx. Oep I I Eastern Su acs Seal Installed by <br /> Repair Work Done 0 T�°of Pump H.P. _ State Work Done_ <br /> Well Destruction 0 Well Diameter �+ SetI tlaterial i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADOITIAN l I DESTRUCTION 1 I INo septic system permitted if public sewer is <br /> -% available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK d Type/Mfg ■ - ___ <br /> g - -Capacity-• -•No:Ctxnpartments <br /> PKG. TREATMENT PLT.C1 + Method of Di+oaal <br /> Distance to nearest: Wall } f 4 ugdation Property Line I <br /> LEACHING LINE Cl No. 6 Length of linea E Totgl Iengthiaire <br /> FILTER BED 0 Distance to nearest: WellFouuridron. _ _ i Property Ljna � <br /> i <br /> SEEPAGE PITS 11 Depth Size <br /> SUMPS Ll Distance to nearest: Well__ _ Foundation1 rropetty-ijne <br /> DISPOSAL PONDS ❑ + �� <br /> I hereby certify that I have prepared this application and that the work will be done in accordan with S899 J quip youh ty ordinances, state laws, and <br /> rules and regulations of the San Joaquin County ; !, <br /> Homs owner or G d agent's signature certifies the following: "I certify that in theLrfonrnan6e ofihe work for which this permssued,it is iI shall not _ <br /> " er7iploy any parso in ch manner as to become subject to workmen's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> •_ - cortitim the If ."I certify that in the performance of the work for which this permit is iss , I shall ernpfoy persons subject to workman's compensa_ <br /> tion laws of fit Is," <br /> The applicant call for ail requir nspection Complete drawing on r `e. - r <br /> Signed Titb: Date: <br /> FOR DEPARTMEN SE ONLY <br /> Application Accepted by _,_ ~ <br /> .�,._.._ Date <br /> Area <br /> �l <br /> Pit or Grout Inspection by Date Final Inspection by Data 3 7 <br /> Additional Comments: <br /> Applicant - Return 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 9520 Qityj',1y <br /> ��A�1 INFO AMOUNT DUE AMOUNT.REMI7TED CASH RECEIVED fly PATE Sf , <br /> • EH 17-31 IllEv,rinse <br /> EH 14.7e �� <br />