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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 O BOX 2009, STOCKTON, CA 95201 <br /> I <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Thi <br /> Application is hereby compliance withuSancounty <br /> J aquinfor <br /> County Ordinancertait to e No. 549 anstruct do1862install <br /> and thethe <br /> Rules andherein <br /> Re Regulations of Sans <br /> application is made in compliance <br /> Y � <br /> Joaquin County Public Health Services. i' �t Size/Acreage It &5 bras <br /> / <br /> City <br /> Job Address <br /> Address <br /> Owner's Name r Phone <br /> c f <br /> icense No. <br /> Contractor W C- —' Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (1 DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION 13SYSTEM REPAIR L7 <br /> OTHER ❑ Monitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES _� - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> n Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation <br /> Type of Casing_ Specifications <br /> f.l Domestic/Private ❑ Gravel Pack L1 Tracy Depth of Grout Seal Type of Grout <br /> 1'1 Public Cl Other r ❑ Delta <br /> I I Irrigation � Appro>t. Depth I 1 Eastern Surface Seal Installed by <br /> of Pum H.P. State Work bone <br /> Repair Work Done U Type `P Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter —Filler Filler Material & Depth <br /> Depth--� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO 1 AIR/ADDITION I I DESTRUCTION•1-1-(N-o sb eltw thin system permitted if public sewer is <br /> •„ "� 1 <br /> Installation will-serve--Re once- Commerciale =O�her <br /> �> Number of living units: Number of be ss 3 '� <br /> y " 1 '1Nater table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK favYl%pe/Mfg Capacity — <br /> \ r - ' Method of Disposal <br /> PKG. TREATMENT PLT. D -­Z <br /> ^Distance to nearest, Well Foundation _!�i__�— Property Line <br /> �, L-F,�,ndib <br /> Total ltrngthlsize <br /> LEACHING LINE L4-�f13-f4 Length of lines -. - - --- - ,FILTER BED ❑ Distanceto nearest: Well ; oils Property Line <br /> SEEPAGE PITS `f-F��spth -J - _Sixe Numbfr <br /> I SUMPS It Ll Distance to nearest: Well�� Foundation Property Line <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 /> llowing: "1 certify that in the performance of the work for which this permit is issued. I shall not <br /> Home owner or licensed agent's signature certifies the fo <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certlfiea 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 /> do of Cafifornl " <br /> The applic st c Ilff all tui c' ns. o to drawing a verse side. -, q3 <br /> r 4 Title: Date: <br /> r <br /> j F R DEPARTMENT USE ONLY <br /> i ii n O Date a2 Area Z <br /> Application Accepted by _(A+' -- s <br /> ! Date <br /> Pit or Grout Inspection by Date��.Final Inspection by <br /> 1 <br /> Additional Comments: <br /> I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> r Enaironmentalz"Heal-tb-Permit/-Services�----- <br /> 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT"REMITTED CA i a RECEIVED BY DA E PERMIT"NO. <br /> 1 INFO � IJ <br /> � � IVB <br /> + E11 17.24(nEV.r i n 51 , <br /> EH 14.25 <br />