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- Y APPLICATION.' <br /> - SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ._ .�Q <br /> ENVIRRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN- PHONE- (209)468=3420 ~ <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT. EgP-IRES" 1 YEAR FROM DATE ISSUED A <br /> COMPMe in TriPlicate} ' <br /> Application isehereby made to San Joaquin County for a permit to_construct and/or install the work herein described. This <br /> application is made in co4liance with San Joaquin Count Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. 4 y <br /> { � � r r <br /> Job Address ef 4 7. <br /> t : City L Lot Size/Acreage <br /> Owner's Name Atldress F <br /> t Dec _ Phone <br /> Vr7�t FLS ■ Ai'���f� 1.�7 �.�'" A <br /> rk Contractor J Address - <br /> TYPE OF WELL/PUMP; — —License No. Phone <br /> NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Nell-r, , <br /> PUMP INSTALLATION 0 SYSTEM REPAIR C1 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES <br /> DISPOSAL FLD, PROP. LINE ; <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> IINTENOpen <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Manteca PITS/SUMPS <br /> E r L7.Industrial F. ! <br /> fl �"° � C] pen Bottom ❑ eca Dia, of We .E.E.c vation y Dia. of-WOJI Casing <br /> C1 Domestic/Private ❑ travel Pack L7 Tracy T } <br /> I'1 Public Type of Casing �5pecifications <br /> F1 Othe► �• C1 Delta ii J Depth of;Grout Sdal <br /> i I Irrigation Approx Depthll-Eastern Type of Grout <br /> Surface Seal Installed bye <br /> _�Repiir.Work Done U Type of Pum' <br /> p ^ H.P y � �r�-"'" •" <br /> State Work Done ` f <br /> Weft Destruction 0 Well Diameter °.Sealing Material b Depth if <br /> DepthFiller/'1 gterial & Depth <br /> TYPEOF.SEPTIC WORK; NEW INSTALLATION F)'REPAIR/ADDITION I 1 DESTRUCTION €.I INo septic system permitted if public sewer'isc• <br /> tavailable within 200 feet.) <br /> Installation will serve: Residence f Commercial— Other <br /> Number of living units:' Number of bedrooms <br /> r Character of soil to a depth of 3 feet: _ <br /> F SEPTfC.TANK s Water table depth f <br /> ❑ Type/Mfg f `= Capacity_ <br /> `-�^PKG:;TREATMENT PLT. L) + No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well € Foundation Pro <br /> r« <br /> perty Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BEDTotal length/size <br /> nto <br /> Cl Distance io nearest: Well ., "foudain <br /> Property Lina <br /> SEEPAGE PITS _ 1.1 _Depth- ISize ;=fi b 4 <br /> SUMPS Number <br /> Ll Distance to nearest. Well Foundation _ <br /> DISPOSAL PONDS Property Line <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, 4mol' <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signatute certifies the following: "I certify that in the } <br /> employ any person in such Manner as to become subject to workman's compensation laws 0!Califarniahe Contractor's fhiring or sub-cont acttinglsignaltu' <br /> certifies the following: "I certify that in the performance of the work for which this permit is iseued,'I shall employ persons subject to workman's compent <br /> tion laws of California." <br /> The applicant must Call for allT re uired inspections. Complete drawing on reverse side. <br /> 1 ' L % y <br /> Signed 11 I <br /> Title: <br /> Date: <br /> FOR DEPARTM N.T. USE ONLY <br /> Application Accepted by <br /> Date Are` a <br /> Pit or Grout Inspection by <br /> ate Final Inspection by / a <br /> Additional Comments: <br /> Applicant - Return all copies}to: San Joaquin County Public Health Services <br /> i <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br />"} INFO AMOUNT DUE AMOUNT REMITTED CK <br /> FH 13-24.INI;V. CASH RECEIVED 6Y DATE <br /> ,� `�► k + - PERMIT'Nq. <br /> ,iKsi 1G r � '^'f � P0 i{ <br /> .- _ ._ t� <br />