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111 . <br /> APPLICATION <br /> SAN JOAQUINCOUNTY PUBLIC "'� ' ` d <br /> ENVIRONMENTAL HEALTH DI IH SERV <br /> 445 N SAN JOAQUIN, PHONE (20 ) — <br /> P O BOX 2009, STOCKTON, C v <br /> PERMIT IRE 1 YEAR FR M <br /> D <br /> (Complete in Triplic <br /> Application is hereby made to Sam Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made 1A complHealthance <br /> with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> / C tyS Lot Site/Acreage <br /> Owner's Name _•� r Tj}s ✓O.rr/l Address <br /> Phone <br /> Contractor1 rL�(t Address <br /> �2�� <br /> License No.&e ,.S22_� <br /> TYPE OF WELL/PUMP: NEW WEL PhO^e <br /> WELL REPLACEMENT C'1 DESTRUCTION ❑ Out of Service hell ❑ <br /> PUMP INSTALLATI N G SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK -`�U % OTHER G Monitoring Well U <br /> SEWER LINES ��� DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL % <br /> INTENDED USE TYPE OF WELL PROBLEM AREA OTHER WELL��_ PITS/SUMPS _ <br /> C1 I <br /> INTENDED <br /> CONSTRUCTION SPECIFICATIONS <br /> G Open Bottom ❑ Manteca Die. of Well Excavation <br /> 1 Domestic/Private CI Gravel Pack ❑ Tracy T Dia. of Well Casing <br /> I'I Public Depth <br /> of Casing_ l5pecifications <br /> VI Other Il Delta Depth of Grout Seal <br /> I IrrrUatron _Approx, Depth f I Eastern Type of Grout <br /> Repair Work Done L3 T Surface Seal Instilled by <br /> YW °f Pump H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material i1 Depth <br /> State Work Done _ <br /> Depth Filler Material Z *Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ' I REPAIR/ADDITION i i DESTRUCTION I I (No septic system <br /> permitted if Public sewn is <br /> Installation will sarve: Residence_ Commercial available within 200 feet.) <br /> _ Other <br /> Number of living units: Number of bedrooms <br /> Character of $ol to a depth of 3 feat: <br /> SEPTIC TANK ❑ Type/Mfg7_ Water table depth Rt <br /> 'KG. TREATMENT PIT. ❑ No. Compartments <br /> Distance to rest: Well <br /> Method of Disposal <br /> "permit m aT ve eXFirec�t�l�/(t 0 � Property line <br /> EACHING LINE ❑ No. & Lengt V@** <br /> ILTER BED ❑ Distance tolno •;Total length/size <br /> ornvirl)II•lt, t�r.'�'P,al�a° It^:L;: Property Line <br /> EEPAGE PITS 11 Depth <br /> LIMPS Size Number <br /> L I Distance to nearest: Well <br /> ISPOSAL PONDS ❑ Foundation _ Property Line_ J <br /> 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 /> Its and regulations of the San Joaquin County <br /> xne owner or licensed agent's signature candies the lolowing: "I certify that in the performance of the work for which this perrrut is issued, <br /> Vloy any person in such manner as to become subject to workman's compensation laws of California.- Contractor's hiring or sub contracting signature I shall not <br /> rtn la the blowing: , unify that in the Performance of the work for which this <br /> Fl laws of California. permit is issued, I shall employ persons subject to workmen's com <br /> Dense• <br /> a applicant rust call for all required inspections. Complete drawing on ever" de. <br /> fined C <br /> • Title: <br /> Date:!c/ <br /> FOR DEPARTMENT USE ONLY <br /> Plication Accepted by r <br /> Date Area <br /> _ Z <br /> or rout spection by }-1 <br /> Date Final Inspection by <br /> lRgnal comments: oat. <br /> Applicant - Return all copies o: San Joaquin County Public Health Services + <br /> Env <br /> tal Health <br /> ces <br /> 4451N°SannJoaquin, P Oe Box 2009, CA 95201 lG� <br /> FEE AMOUNT OUE <br /> CCi <br /> i I f0 AMOU�11EIAIT�7ED RECEIVED BY <br /> CASH OATE PERMIT NO. <br />