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APPLICATION . { <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N 'SAN JOAQUIN, PHONE (209)46$-3420-. <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> V"T "` IRES'""]�""YEAR'rFROI DATE' I,'�SUED� �t�rww� <br /> 'P-ER%IT-E%P <br /> _ (Complete"in -Triplicate) - <br /> Application 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 compliance,vith San Joaquin County Ordinance No. 549 and 1862 and the.Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �M � �., ��:� Lot Size/Acreage v, <br /> Job Address c <br /> t Phone <br /> Owner's Name ddress Z.. 0 r r <br /> 1 -- <br /> Contractor <br /> Address Z License No. �_ 5 Phone ; <br /> TYPE OF WELL/PUMP: NEW WELT _ WELL'-REPLACEMENT n DESTRUCTION Out of Service Well <br /> r OTHER El <br /> Monitoring Well <br /> PUMP INSTALLATION J, '+ r l SYSTEM REPAIR L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWERR LIN DISPOSAL FLD:f_75" PROPS LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> tP <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS'. _ Shct <br /> f_7 Industrial pen Bottom 11 Manteca Ola,of Well E"xcavation <br /> Dia. of Well Casing f c� <br /> omestic/Private ❑ Gravel Pack ❑ Tracy i <br /> Type of Casng_ <br /> ;�U� Specifications.. <br /> \ t i Type"�'f out r <br /> f'lPublic 1-1 Other fl Delta Depth of Grout Seal � � V � <br /> V <br /> � i I I"rrigation � ' .Approx.'Depth I 1 Eastern Surface Seat Installed by <br /> H.P. State Work done <br /> Repair Work Done U Type of Pump -- � ;r,. ''^ <br /> Sealing Waters Depth # ' <br /> Well Destruction ❑ Well Dia r Filler ria! 1. Depth <br /> Dept ,.r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I' REPAIRlADOITION i I DESTRUCTION I I aNailablparw thin 200!setljc system tled if public sewer is ': 1 <br /> - r r ..1 <br /> r ' Installation will serve: Residence____ Commercial Other -- <br /> Number of living units: Number of bedrooms <br /> o! soil to a depth af_3'feeCte table depth <br /> Character l <br /> SEPTIC TANK ❑ -ripe/Mfg. Capacity '�.`,No.�Compartments <br /> �I1Aethod of Dip sal-- <br /> PKG. TREATMENT PLT: ❑" <br /> ` Foundation �PropartyrLiAS ` <br /> Distance to nearest: ell _ t <br /> •' LEACHING LINE 0 No. & Lengt lines Total length/size <br /> FILTER BED n Distance nearest: Well Found on Property Line — <br /> SEEPAGE PITS 11 nth Size _ Number <br /> } <br /> SUMPS LI Distance to nearest: Well foundation Property Liner i <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 ordinanc 1, state laws;grid <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I 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 Cal'ornia." f ; <br /> The applican st ired ins tions. Complete drawing on reverse sid . �— <br /> Date: I <br /> Signed Title: <br /> FOR DEPARTMENT USE ONLY q _ ; <br /> ' Date _��,� -- —— Area 'L k-9 <br /> Application Accepted by <br /> rDate t <br /> Date Final Inspection by <br /> Pit or Grout Inspection by <br /> Additional Comments: `J r <br /> Applicant - Return all copies to: San Joaquin o ty Public Health Services 4 <br /> Environmental Health Permit/Services <br /> 445 N San Joaquiri P O Box 2009, Stkn, CA 95201 ; <br /> CK /+ "REgv LVED BY DATE PERMt7"NO. . <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> { INF ,p / { <br /> C . EH,9.2,IREY.,,ns, JS-2 5:3 21 <br /> EH 14.20 <br />