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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 /> f P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> in described. <br /> Application is hereby made,toSan �oahu $BnC� nty aquinor a CountyrOrdlnanceto nNo. 549sitruct aando1862sandlthe the <br /> Rules anwork hed Regulations of Sans <br /> application is made in camp a <br /> Joaquin County Public Health Services. <br /> k"I L ZE- T H [„ CityTKW Lot Size/Acreage <br /> - , Job Address _ 1 r {' Q <br /> �6 R Address Zl '2' Phone ` 1 <br /> Owner's Name 1 License Nophone <br /> q_svo � r <br /> Contractor No 0 { Address <br /> .-��'��� <br /> TYPE OF WELL/PUMP: , NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION OTHER Q Out or service Well <br /> Monitoring Well <br /> SYSTEM REPAIR 0 <br /> XPUMP INSTALLATION e <br /> SEWER LINES -- - DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Cl Industrial ❑ Open Bottom [3Mantanteca Dia. of Weil Excavation_ Specifications., - <br /> ' Type of Casing <br /> Ytd%Domestic/Private ❑ Gravel Pak ❑ Tracy Type of Grout <br /> I'1 Public to Other ❑ Delta Depth of Grout Seal <br /> t I Irrigation .Appro Depth I I Eastern Surface Seal Installed by <br /> H p ._ : State Work..Done•— <br /> Repair Work Done L7-_:Type.of Pump `"rte=-= f —Ma Crrv"Z 14 <br /> Sealing Material 8 Depth 'T <br /> Well Destruction ❑ Well Diameter Biller Material & Depth u�t r Q <br /> Depth 00 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (hvailabeSeptic <br /> Shin System <br /> permitted if public sew <br /> s► is <br /> Installation will serve: Residence Commercial t Other -- <br /> Number of living units: Number of,bedrooms Water table depth <br /> Character of soil to s depth of 3-feet: No, Compartments <br /> SEPTIC TANK ' C) Type/Wg_- Capacity <br /> Method Of Disposal <br /> PKG. TREATMENT PLT, ❑ • :. r <br /> r <br /> Distance to nearest: j Well Foundation Property Line , <br /> Total length/size <br /> LEACHING LINE L"1 No. &_Length of lines <br /> FILTER BED. ❑ Distance to nearest: Well Foundation Property Line <br /> - i <br /> j t Number <br /> Irl SEEPAGE PITS I i Depth Size <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <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 ordinances, state laws, and <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, l shall employ persons subject to workman's compensa• <br /> tion laws of California." <br /> 1 The applicant must call for all required inspeptio . Complete drawing on reverse si <br /> Signed <br /> Title: Date: <br /> F R DEPARTMENT USE ONLY <br /> Date <br /> Area <br /> Application Accepted by <br /> i Date <br /> Pit or Grout Inspection by Date Final inspection by <br /> AdditionalComments: 1 <br /> Applicant - Return all coipies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> I <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DGS AMOUN REMITTED CASH <br /> r 13-24(REV.��»51 �S 6D . 5- <br /> EH <br /> i EH 14.26 <br />