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Job Address <br />Owner's Name <br /> <br />Address <br /> <br />gu ations of San <br />SAN JOAQUIN COUNTY PUBLIC HE <br />ENVIRONMENTAL HEALTH DI <br />445 N SAN JOAQUIN, PHONE (2 <br />P 0 BOX 2009, STOCKTON, <br />oncEs 220 pf; <br />PERMIT WIRES 1 YEAR FROM r , MAUD ...---.---------- <br />(Complete in Triplica e) <br />Application Li <br />application is <br />Joaquin County <br />TYPE OF WELL/PUMP; NEW WELL <br />PUMP INSTALLATION CI <br />DISTANCE TO NEAREST; SEPTIC TANK SEWER <br />FOUNDATION AGRICUL <br />Contt-attor <br />hereby made.to San Joaquin County for a permit to construct a <br />made in compliance vith San Joaquin County Ordinance No. 549 <br />Public Health Services. <br />tidress <br />WELL REPLACEMENT 17 DESTRUCTION Cl Out of Service Well <br />SYSTEM REP IR :-.11 OTHER Cl Monitoring Well ci <br />NES DISPOSAL FLO.- f ROP. LINE <br />RE WELL OTHER WELL FITS/SUMPS <br />,ft City <br />Licente -s-!Ost Z <br />Size/Acreage ' <br /> <br />u ee <br /> <br />'hone 3<'- 93S6 <br />TYPE OF WELL PROBLEM AREA <br />0 Open Bottom 0 Manteca <br />• 0 Gravel Pack 0 Tracy <br />I.1 Other 1-1 Delia <br />Approx. Depth I Eastern <br />Type of Pump M.P. <br />Sealing <br />UCTtON SPECIFICATIONS <br />Well Excavation Dia oi Well Casing <br />ol Casing Spucifications <br />of Grout Seal Type of Grout <br />Seal Installed by <br />State Work Done' <br />INTENDED USE <br />D Industrial <br />11 Domestic/ Private <br />I'S Public <br />i Irrigatkin <br />Repair Work Done <br />Well Destruction 0 Well Diameter <br />Depth <br />TYPE Of SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I <br />Installation will serve: Residence __VCommercial Other <br />Number of living units: - Number of bedrooms '4.5 <br />SEPTIC TANK 0 •Type/Mfg <br />Character of loll to a depth of 3 feet: <br />Capacity /SO ° <br />PKG. TREATMENT PLT. 0 <br />Distance to nearest: Well : <br />LEACHING LINE <br />FILTER BED <br />O No. & Length of lines (q) <br />0 Distance to nearest: Wen /0(.1- Foundation <br />SEEPAGE PITS I / Depth Siva <br />SUMPS LI Distance to nearest: Well oundation <br />DISPOSAL PONDS <br />I hereby certify that I have prepared this application and that the work will be done in accordance with n <br />rules arid regulations of the San Joaquin County <br />Home owner or licensed agent's signature certifies the following: "1 certify than in the performance of the <br />employ any person in such manner as io become subject to workman's compensation laws of California." <br />certifies the following: "I certify that in the performance ol the work for which this permit is issued. I shall empi <br />lion laws of California." <br />Dep <br />Surfs <br />S-C1 Foundation <br />aqui unty ordinances, state laws, and <br />icin this permit is issued, I shall not <br />ior's feting or sub-contracting signature <br />mons subject to workmen's compensa- <br />Material & Depth <br />DESTRUCTION I I No septic system iermitied if public sewer is <br />available within 200 feet.1 <br />Water table depth <br />No. Compartments <br />Method of11.105a4 <br />Property Line 3 <br />Tiller Material & Depth I <br />9- 2a-93 call for eLi red ins bons. Complete drawing on reverse side. <br />Signed Title: <br />Application Accepted by C°- Q <br />tr"r".415.- --.../ --I <br />Detei <br />FOR DEPARTMENT;USE ONLY <br />t <br />k <br />Pit or Grout Inspection by Date Final Inspection by al Fir? <br />Comments: i.. L.. <br />Applicant - Return all copies to; San Joaquin County Publiic Health Se4ices <br />Environmental Health Peialt/Servicee, <br />445 N San Joaquin, P 0icitigtbig -lit*, CA 9520 <br />The applicant <br />ee)49 <br />0/13' Area <br />fari./2LJ Date 9 -4,343 <br />. EN 13-24 IMO", /AS <br />Ex 14.2a <br />FEE AMOUNT OtJE INFO CA AMOUNT REMITTED RECEIVED BY 11 DATE <br />/ / 41 a 114' azi , (2 0045-- 1352/ 9/21)/3 'RP";