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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 /> P O 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 to construct and/or install the work 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 Vervices. <br /> Job Address City_ eage <br /> }- Lot Size/Acr <br /> Owner's Name Address L=Lf&W Phanid <br /> J <br /> u Cpntract Address Licerise Pho <br /> I TYPE OF WELL/PUMP: NEW WELL ❑- WELL REPLACEMENT F DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ca Domestic I Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I'I Public Cl Other ii fl Delta Depth of-Grout Seal Type of Grout <br /> I I Irrigation _ Approx. Depth' . I I Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump H.P. State Work Done <br /> Well Destruction r ❑ Well Diameters-y Sealing Material & Dept I <br /> tDepth 'Filler Material,& Depth Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION DESTRUCTION (No septic system permitted it public sewer is <br /> f available within 200 feet.) <br /> Installation will serve: Residence Commercial Other( <br /> Number of living units: _ Number of bedrooms <br /> 3 Character of soil to a depth of 3 feet: <^.,LAWater table depth <br /> SEPTIC 7AN1C '0TypaJmf' L ___--_ Capacity_ No. Compartments i <br /> t PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well f _ Foundation Property Line <br /> LEACHING LINE SSV No. 8&l4ength of lines ' )lila) length/size <br /> FILTER BED ❑ Distance oto nearest: Well Foundation.- Property Line <br /> SEEPAGE PITS 11 Depth ! Size 1 %-"f T Numbsr F <br /> SUMPS Ct ,/Distance to nearest:T Well fi Foundation-i Property Line <br /> r 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 ordinances, state laws, and <br /> /rules and regulations of the San Joaquin County <br /> i 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 compaA5 ation 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 California. <br /> f The applicant for all require. in".. ions.,Compl a drawing-on•reverse side..' i . <br /> C r <br /> -T <br /> ¢. <br /> Signed itle:-` Date:g � 11/0 <br /> TMEfHT USE'ONLY <br /> t Appficatlin Accepted byaN. r Date D z-- Area 0�— O <br /> Pit or Grout Inapectioniby Date Final Inspection by Date K <br /> Additional Comments: <br /> s <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 4 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 I <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY {SATE PERMIT'NO. t <br /> l a INFO . .._. ........ _ ... _ .-... -._. w.CASH _._.. ._. <br /> r EHt3-34IREV.rinsi <br /> EH t4.7e Ll <br />