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APPiICATION. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> t PERMIT MIRES 1 YEAR FROM DATE ISSUID <br /> Pe,pw t r (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.X1+9 and 1862 d�— to , <br /> > a Regulations of San <br /> Joaquin County Public Health Services. "T�` ! �- Cl <br /> City 5'T�L-. Lot size/Acreage <br /> Job Address <br /> r <br /> e <br /> Owner's Named Address <br /> 7 L �Af 4Q_License No,7,��Phone <br /> Contractor c7 !1 G Address �-'_�r DESTRUCTION ❑ Out of Service Well Gl <br /> TYPE OF WELLJPUMP: NEW WELL ❑ - - WELL REPLACEMENT ❑ Monitoring Well �� <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR-X OTHER 13 <br /> SEWER LINES __�— --- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _�—.-- AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing �I <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing_ Specifications <br /> f7 Ty <br /> Domestic/Private ❑ Gravel Pack El Tracy Typth of Grout Seal Type of Grout.-.. <br /> 1'1 Public 1:1 Other i Cl Delta <br /> Irrigation -Approxi Doh , I Easter SurfaceSealInstalled by <br /> H P State Work Done <br /> Repair Work Done TY of,Pump XG:a - Sealtng rial tc Depth <br /> Well Destruction ❑ Well Diametir Filler Material & Depth <br /> Depth. <br /> TYPE OF SEPTICWWORK., NEW'INSTALLATION I 1 REPA1RIfADDlTION I ] DESTRUCTION I I avlailableic system w thin 200 ied it public sewer is <br /> feet1} <br /> Installation will serve:' Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK. © Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. L1 Property Line <br /> Distance to nearest: Well Foundation Pe V <br /> s <br /> +� Total length/size <br /> LEACHING LINE ❑ No. & Length of tines Property Line <br /> FILTER.4ED C] Distance;to nearest: Well Foundation <br /> Size Number <br /> SEEPAGE P175 I l Depth Property Line <br /> SUMPS LI Distance to nearest: Well Foundation <br /> 7 <br /> DISPOSAL PONDS ❑ '"r f <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 shalt not <br /> "to become subject to workman's compensation jaws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in such ttianner as <br /> certifies the folldwing:"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 Caf fornis." .1 'I, <br /> The applica ust ca for all required.inspections. omplete drawing an rf/si�de. <br /> Title: ;S Date: <br /> Signed _ <br /> FO D ENT USE ONLY <br /> -c- -�- <br /> Date Area <br /> Application Accepted by f y <br /> Pit or Grout inspection by Date Final Inspection by <br /> __ Date�r <br /> Additional Comments: r <br /> Applicant - Return all coi pies to: San Joaquin County Public Health Services <br /> Environmental Health'Permit/Services <br /> 1• 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> r <br /> FEE CK RECEIVED B <br /> INFOY DATE PERMIT'N0. <br /> AMOUNT DUE AMOUNT REMITTED <br /> pF . EH 13-24 tREV. <br /> r EH t4-IO t <br />