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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> iP O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR ROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> r <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. c This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services . <br /> ,1 <br /> Job Address <br /> `.L 5' �/ City Lot Size/Acreage <br /> Owner's NameLL <br /> Address <br /> SArm E Phone <br /> Contractor_ FGo Z j5, Address A, A' —'-! . 1469 License No.IA�74 Phone -7/ <br /> TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ('7 DESTRUCTION ❑ art of Service Well C_l <br /> PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0- •Industrial ❑ Open Bottom ❑ Manteca Dia.-of Well Excavation Dia. of Well Casing <br /> ❑ Trac Type,of Casing- ' Specifications <br /> fJ DomesticlPrivate ❑ Gravel Packs Y r ) a <br /> I"1 Public [:7 Othaf;r } F1 Delta T —6epth of Grout Seal Type of Grout <br /> + I Irrigation Approl%'Depth I I Eastefn Surface Seat Installed by <br /> Q) i <br /> Repair Work-Done__U Type of Pump H.P. State Work Done_. n <br /> Well Destruction ❑ Well'Diameterh} Sealing Material & Depth �J <br /> Depth I Tiller Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted it public sewer is <br /> } { - available within 200 feet.I <br /> Installation will some: Residence Commercial Other <br /> l <br /> Number of living units: Number o1�bedrooms-"--• <br /> Character of sail to a depth of 3 feet: } 6-4 Water table depth <br /> SEPTIC TANK. © Type/Mfg 4 JSX IS r I A-i& Capacity'f No. Compartments <br /> PKG. TREATMENT PLT,❑ - 5� Method of Disposal ; <br /> i, <br /> Distance to nearest: Well Foundation `� Property Line <br /> LEACHING LINE Or No. 6 Length of lines t' g th/size <br /> Total len <br /> FILTER BED ❑ Distance to nearest: well. '2-00- .Foundation = <br />