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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 $O% 2009, STOCKTON, CA 95201 <br /> + RMITY., IRES 1 YEAR FROM DAIE ISSUED <br /> (Complete in Triplicate) <br /> e to Sa1iJoa u1n County for a permit to construct and/or Install the vork herein described. This <br /> Application is hereby mad 4 <br /> application is made in coa�lianeeivith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. <br /> t • �►�- <br /> �1 City�� �`rim Lot Size/.Acreage �, f <br /> 1X Job Address p /' <br /> Yyy„ S�}/1D /r/t Address <br /> Phone <br /> Owner's Name <br /> N L —Address- fir"`-e- _ -- License No. Phone <br /> Contractor <br /> YPE OF WELLIPUMP: NEW WELL.❑ WELL REPLACEMENT l� DESTRUCTION ❑ Out Monitoring Well <br /> PUMP INSTA'LLATIONX SYSTEM REPAIR C1 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENOEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ' <br /> n Industrial ❑ Open Bottom ❑ Manteca' Dia. of Wall Excavation Specifications <br /> r:3 Domestic/Private ❑ Grovel Pack n Tracy Type of Casing_. .� <br /> I'1 Public <br /> f-1 Other Cl Delta, Depth of Grout Seal Type of Grout <br /> , <br /> I Irrigation ._ Approx.IDepth <br /> ,k I Ea;tern Surface Seal Installed by <br /> (f SUL H,P. State Work Done <br /> Repair Work Done U Type of Pump - -Sealing Material. 8 Depth <br /> Well Destruction ❑ Well Dismete� - i <br /> Depth Filler Material 6 Depth <br /> TYPE OF—SEPTIC-WORK: NEW INSTALLATION I I REPAIRIADp1TION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence ` Commercial Other - <br />{ Number of living units; Number of bedrooms t7 <br /> Character of soil to a depth of 3 feet:i Water table depth <br /> SEPTIC TANK ❑ Typa/Mfg` Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 t Method of Disposal <br /> Distance-to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of linea Total length/sire <br /> FILTER BED n Distance-lo nearest: Well Foundation Property Line I <br /> ,f <br /> SEEPAGE PITS It Depth ' Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS © 1 Z <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 Sen Joaquin County t shall not <br /> Home owner or.licensed..a9ent's signature certifies the foliowing: "t certify that in the,performance of the work for which this permit is issued, <br /> !! employ any person in such manner aftib bec a eubjsct to workman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> : "I certify that in the rf rmence of the work for which this permit is issued, I shall employ persons subject to workman's eompanae <br /> conifies the follo�' <br /> lion lawa of tom! ; � <br /> M <br /> The app' equued in ctions..Complete drawing on rave da. <br /> Signed �-� Title: �fl _ Date: <br /> FO DEPARTMENT USE ONLY <br /> Date ^� S ea <br /> O <br /> Application Accepted by <br /> Pit or Grout Inspection by ii- <br /> Date Fine Inspection by Oate <br /> 1 1 r <br /> 11 � <br /> Additional Comments' n <br /> I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> ;j Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Sox 2009, Stkn, CA 85201 j <br /> FEE AMOUNT DUE AMOUNT REMITTED A5 RECEIVED BY ATE PERMIT'NO. <br /> i. INF ` 17 <br /> y� <br /> (��J t 1 .✓c �� �° L 4 <br /> ' EH 1 .14 IAEV.v/n 51 �Y1' <br /> Ek 11.29 1 <br />