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v APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 NP O BOX 2009, STOCKTON, CAUIN, PHONE 95201PERMIT EKPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> in <br /> Application is hereby made,tiaBan �oahuiSnanCSo$quin County Ordinanceermit to nNo. 549struct gand o1862 and the r install eRules anwork d Regulations dof Sans <br /> application is made in cornpl <br /> Joaquin county Public Health Services. <br /> p E City -� Lot Size/Acreage <br /> Job Address V ii 5._6L?11f_ <br /> t Phone <br /> C t Address <br /> Owner's Name ZZ,, <br /> Contractor Address 4• <br /> .( License No.2L?Phone to Jr�v <br /> WELL fiFFLACENMIN [7 <br /> NEW WELL ❑ DESTRUCTION Cl Out of Service Well ❑ <br /> TYPE OF WELLIPUMP: OTHER ❑ Monitoring well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 <br /> SEWER LINES �---- DISPOSAL. FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITStSUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED,USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ClOpen Bottom ❑ Manteca Dia. of Well Excavation <br /> n Industrial Specifications <br /> L7 Tracy Type of Grout <br /> Type of Casing_ <br /> f] Domestic I Private ❑ Gravel Pack Depth of Grout Seal <br /> it Public f 1 Other Q Delta <br /> I I Iffloation —..Approx. Depth I I Eastern Surface Seal Installed by <br /> _ H P State Work Dona <br /> Repair Work Done- U Type of Pump Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter Filler Material & Depth <br /> Depth <br /> ermiTYPE OF SEPTIC WORK. NEW INSTALLATION I i REPAIR/ADDITION DESTRU ION INem <br /> aildbptic hit 200 lest.) it public sewer is <br /> Installation will serve: Residence .X Commercial� Other ay `;l (� <br /> Number ai living units: _L_ Number of bedrooms- / 1 <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK �9; Type/Mfg , �,..� -- — Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT, Cl <br /> Distance to nearest: Well ___4 <br /> P� Foundation g&J4__ - Property Line <br /> — <br /> i <br /> LEACHING LINE � No. & Length of lines � r� Q i <br /> r <br /> x <br /> FILTER BED ❑ Distance to nearest: Well�}�.� Foundation ��/Total lengthlsi2e Property Line e <br /> r <br /> Size <br /> Number <br /> SEEPAGE PITS Jy4 Depth / <br /> Well <br /> SUMPS LI Distance to nearest: 1��rr Foundation Property Line <br /> — <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; "!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 California." <br /> rk <br /> The applicant call for al uired inspections. Complete drawing on reveZL� <br /> Title: <br /> �6Date: <br /> Signed x . <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> to <br /> Pit or Grout Inspection by <br /> Date -- Final Inspection Da <br /> Additional Comments: <br /> - t <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 95201 <br /> FEECK RECEIVED BY DATE PERMIT'NO. <br /> AMDUNT DUE AMOU T REMITTED H / <br /> INFO D� <br /> EH 13-24 Il r/1`15) p'b /f <br /> 'y/ ! <br /> EH 74-2e r <br />