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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 />! <br /> P. 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete-in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit-tam construct and/or install the vork herein described. This <br /> application is made in compliance 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�� �`J ` City Lot Size/Acreage <br /> Owner's Name ` , AddressITA <br /> Phone <br /> ?3-1— Z!54 <br /> � 5f�!it Ad es "^ tc nee N L7 Phone <br /> ontt 6F <br /> TYPE OF WELL/PUMP: NEW WELL � 'WELL REPLACEMENT P DESTRUCTION ❑ out of Service Well 0 <br /> PUMP INSTALLATION ; SYSTEM REPAIR 0 OTHER CI Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> _ _ _ <br /> FOUNDATION- - - --AGRICUVTUAEyWELL-- -- -OTHER-WELL -- PITS/SUMPS, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> — <br /> n Industrial 0 Open Botiom C1 Manteca Dia: of Well Excavation Dia. of Well Casing <br /> U. omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specilications . <br /> I'I Public fa Other n Delta Depth of Grout Seal Type of Grout <br /> - i I trn ation —.Approx. Depth I I Eastern Surfs Seal I stalled by <br /> 14 <br /> k Repaid Work Done ❑ Type of Pu ip !wb H.P. ' State Work Da <br /> Weil Destruction O Well Diameter � t 1,gling Materi & Depth <br /> r Depth Z';10' Filler Material & Depth <br /> k TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation wig serve: Residence_-1 Commercial_ Other r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet - - Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity 'No: Compartmemi, <br /> - <br /> PKG. TREATMENT PLT.❑ '` Method of DispoBal <br /> I Distance!to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> F <br /> SEEPAGE PITS 11 Depth Size Number <br /> 1 <br /> SUMPS LI Distancel1to nearest: Well Foundation Property Line <br /> F'. DISPOSAL PONDS 0 I <br /> I hereby certify that I have prepared thi''s application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sen Joaquin County <br /> i_ Home owner or licensed agent's signature certifies the following:-"t certify that in the performance.of the work for which this permit is issued. I shall not <br /> F( employ any,perion in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> F certifies the following: "I certify that-in.the performance of the work for which this permit is issued, I shall smploy persons subject to workman's compensa- <br /> tion laws of-California." <br /> .The appliceKrnust calAor all required inspections. Complete drawing on reversk side. <br /> • r �� �� <br /> s Signed 111-G..� - Title: Date: <br /> FO X_.._. <br /> Application Accepted by_ ArA& _.._ _-- Date ��°�� �` Area <br /> If !9�`a <br /> Pitlor Grout Inspection by 1 - Date Final Inspection by Date <br /> Additional Comments:i <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> ' ! Environmental Health Permit/Services <br /> r 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT'NO. <br /> INFO <br /> . EH 13-21 tREV.1iM51 Q �.�1.^., `a - <br /> fH 14•26 1 <br />