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SAN A,. UIN COUNTY PUBLIC HSAI.TH VICES <br /> ENVIRONYSNTAL HEALTH DIVZSIOA <br /> 445 N SAN JOAQUIN, PHONE (209)46$--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (Complete in Triplicate) <br /> 1lpplication is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in 00421ance vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules sad Regulations of San <br /> Joaquin County Public Health Services. <br /> Job AddressCK City. Lot Size/Acreage <br /> neMM")IM a —r ���i�[Ac� � <br /> Owner's Name O <br /> Address -A Y �sfic ,_ Phone 4 —g29 2 <br /> ilk <br /> Conlraclor Address • LA Li1�cens�elNo. eJ12.?�Pno,e O� <br /> TYPE OF WELL/PUMP: NEW WELL PA WELL REPLACEMENT rl `D�-E�lSTRUCTION 0 Out'of Se WE ❑ <br /> PUMP INSTALLATION ❑ SYSTEMS,REPAIR ❑ -7 W^JSOTHER )W Itonitoril*well <br /> DISTANCE TO NEAREST: SEPTIC TANK ,r SEWER LINES _ D '�^. DISPOSAL FLD, ROP. LINE }Lam'# <br /> 7► - <br /> FOUNDATION . �'?t'r• AGRICULTURE WELL ""` OTHER WELL PITS1 LIMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUMON ikCIFICATIONS <br /> G Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Casing <br /> Domestic/Private kl Gravel Pack ❑ Tracy Type of Casing PWI Specifications <br /> I"1 Public M Other Delta Depth of Grout Seal Type of Grout 1T T <br /> I i Irrigation O.Approx. Depth I I Eastern Surface„Seal Installed by -i���-• <br /> s <br /> Repair Work Dona U Type of Pump H.P. State Work Done z. <br /> Well Destruction ❑ Well Diameter Kim. Sealing Material S Depth <br /> til( Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.I <br /> Inslobtlon will servo: Residence___. Commercial_,_.. Other <br /> Number of living units: Number of bedrooms <br /> Character of Gall to a depth of 3 feet: Water table depth <br /> SEPTIC:TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT,O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line i <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS L1 Distance to nearest* Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I ler�'oarafy that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sure laws, an <br /> rules and regulations of the S9A Joaquin County <br /> Hone owner or licensed agent's signature certifies the following; "1 certify that in the performance of the work for which this permit is issued, t shall not <br /> employ any person In such manner as to become subject to workman's compensation laws of California."Contrector's!tiring or sub-contracting aig�tetlres <br /> cortHiae the following:"I certify that in the partone►ance of the work for which this permit is issued,1 SMII employ persons subject to workman's compensa- <br /> tion laws f CaNfornle." <br /> The a must for#NqukW inspections. Complete drawing on reverse side. <br /> r + icy Spesd Title: t :Zvi <br /> FOR EPARTMENT USE ONLY r <br /> AppNcation Acespted by IVLAIA WE Date Area <br /> Pit or Grout Inspection by � Date Final Inspection by Data <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 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH�s RIVED BY DATE FiNo. <br /> SOV J 'J�] 4 113 f✓ <br />