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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 I 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 9ervicca. \ / <br /> Job Address City -�� Lot Size/Acreage = <br /> Owner's Name AM Phone <br /> Contractor <br /> ,/) Lf it, � `�ti' Addresst- erase No, k' Phone <br /> TYPE OF_WELL/P.UM.P- _-�NEW WELL f� WELL-REPLACEMENT_:_C-1 DESTRUCTION ❑ out of Service well Cl <br /> PUMP INSTALLATION 0 SYSTEM REPAIR_ ❑ OTHER ❑ Moni?or'n4 AZ1 L7 <br /> -DISTANCE TO NEAREST,: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial D Open Bottom:, , r 0—Manteca' Dia. of Well Excavation J, Did. of Well Casing <br /> Dom4Iic/Private ❑$Uravet Pack, L� Tracy Type of Casing- <br /> [I 3 Specifications` <br /> I•I Public fa Other f 4 Delta, Depth of Grout Seal Type of Grout <br /> t I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work,Done 0Type of Pump H.P. __ Stats Work Done' <br /> \ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth, Filler Material_&_Depth <br /> TYPE OF SEPTIC WORK: NEWIINS.T.ALLATION_I,I—REPAIR./ADDITlON_I_.� ST.RUCTION I_L.(No.septic,system permitted if public sewer is <br /> available within 200 feet.) j <br /> Installation wil(serve: Residence_ Commercial Z�Other. <br /> Number of living units: as Number of bAOroocns <br /> r <br /> Character of soil to a depth of 3 feet: L�'_iL___ ___ _ : Water table depth + <br /> SEPTIC TANK L.___ h-"TvWMfg1 Capacity ` No-Compartrnentsi <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance t nearest: Well Foundation Property Line <br /> LEACHING LINE" . & Length of lines # Total length/size <br /> FILTER BED )n Distance to nearest: Well�_ Foundation .. -r Property Line , <br /> SEEPAGE PITS I*--V_�pth __` Sire 4 Number <br /> SUMPS 'Cl Distance to nearest: Wel! Foundation <br /> �_ IProperty tine S <br /> DISPOSAL PONDS El <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 t <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 man er as to become subject to wor men's compensatiori laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in thepertormpnce of'ffie work for wFiicFi'tfiis permit-ia issued, I shall employ persons subject to workman's compensa- <br /> t' of California." <br /> The applic rat cal far all reg din ti ns.1 �Ietdrawing on r rse std9 <br /> Signe f ` -- Title. 7n moi.( 1 _Da e: <br /> FOR DEPARTMENT USE ONLY L <br /> Application Accepted by _�e�y F rs �f d7� Data r Area r <br /> )r ) 6 i <br /> or Grout Inspection by Date Finsl Inspection b - Date <br /> Additional Comments: <br /> t <br /> Applicant - Return all copies to: San Joaquin County Public Health Services r <br /> t Environmental Health Permit/Services <br /> I[ 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO (AMOUNT DU t, AMOUNT REMITTED CASH RECEIVED BY giATE PERMIT NO. <br /> EH 13.24 tNEv.+r as) <br /> EH 14.20 I ttPP !!JJ <br />