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APPLICATION I <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 /> dinance Po. 5k9 and 1802 and the Rules and Regulations of San <br /> application is made in conpliance with San Joaquin County Or <br /> Joaquin CountyPublic Health SeryI cefi. lI <br /> ;{, city <br /> v Lot Size/Acreage <br /> Job Address a4h .. <br /> Address Phone <br /> Owner's Name ,, ., <br /> L Address 3 License No. Phone O <br /> Contractor _ p <br /> TYPE'OF WELL/PUMP: NEW WELL=1 WELL REPLACEMENT - DESTRUCTION ❑ Out oP service Well .(3 h <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> OTHER ❑ Monitoring 41e11 <br /> SEWER LINES D SPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK __�—___�—� <br /> FOUNDATION• AGRICULTURE WELL OTHER_ WELL PITS/SUMPS <br /> �. .' IN7.ENDED.USE' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Pia. of Well Excavation pia. of Well Casing <br /> 0 Industrial "� ❑ Open Bottom�i (71 Manteca <br /> Type of'Casing_� Specifications <br /> Domestic/Private Cl Gravel Pack ❑ Tracy' Type of Grout {\ <br /> 1'l.Ptiblic Cl Other: n Delta Deft. of;Grout Seaif' <br /> I I Irrigation __..Apprax. oe. 91 Eastern Surface Seal Installed <br /> H P - State Work Done 4 <br /> Repsir!Work Done L7 Type of Pump Sealing Material & Depth <br /> ' d <br /> Well Destruction ❑ Wali Diameter —�- ,. f <br /> Depth ; � ; Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION, l 1 �rRE�AIRlADDITION I I DESTRUCTION I I ofvailable'c system wthin 200lest.Ir MCI-rf pubh�c sewer is <br /> Installation will serve: Residence'— Commercial ^L Other <br /> Number of living units: Number of bedrooms Wa P Y NT '< <br /> Character of soil to a depth of 3 feet <br /> ❑ Typo/Mfg v Capacity— <br /> SEPTIC <br /> TANK Metficf �sdasa� , <br /> PKG. TREATMENT PLT. ❑ <br /> Distance,to nearest: Well Foundation Pr ape���n �{JNTY..� <br /> Total leEHbJ <br /> LEACHING UNE Cl No. & Length,of lines <br /> , N1 <br /> FILTER BED F) Distance-to nearest: Weil Foundation Property Line <br /> SEEPAGE PITS 11 Depthf Size Number <br /> SUMPS Ll 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: "t certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any per in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> Certifies the <br /> Poll wi g: "1 certity that iEk the pdrtormsnce of the work for which this permit is issued, I ham employ pens subject to workman's compens <br /> -laws- f nia:' ^s^k'.,,,",:--."'.� <br /> The applic t at call for all requir inspectio omelets drawing on v r side. <br /> t Signed X <br /> .,.� Title:"' . Date: O <br /> f FOR DEPA_'RTME T USE.,ONLY �.. ,, <br /> Date Area ' <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by eta 4#13 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Pe it/Services' <br /> 445 it San Joaquin, P O x 2009, Stkn, CA 95201 <br /> FEE DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO, <br /> INFO AMOUNT W <br /> � <br /> . EN13-24 IR[V. <br /> } EH 114.20 <br />