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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Y ENVIRONMENTAL HEALTH DIVISION <br /> . 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 4 <br /> a <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) i <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 conVliance with San o q ofut a e 54� d the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Joh Addres Q .. 1 ~��, City Lot Size/Acreage <br /> Owner's Name _ dF' /K�J _ Addressf-6- U 1d2 9! 9iT74 Phone <br /> CiRCJ S-Frd�LICV c No.C� Phone r <br /> Contractor dress M <br /> TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION C) Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERJ Monitoring Well 17 <br />} E 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 SPECIFICAT101�S -&X 0 !/ <br /> ❑ Industrial ❑ Open Botiom ❑ Manteca Dia. of Well Excavation P- Dia. of Well Casing <br /> C3 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other 171 Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation _,Approxi Depth I I Eastern Surface Seal Installed by @ <br /> Repair Work Done L3 Type of Pump H.P. State Vior(C D <br /> Well Destruction C3Well Diameter Sealing Material d Depth 4 CJ f' a <br /> Depth [ Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) , <br /> Installation will serve: Residence Commercial^ Other <br /> I <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity- <br /> PKG. <br /> apacity PKG. TREATMENT PLT.❑ 05p, <br /> I <br /> s Distance to nearest: Well Foundation Prop y Line C <br /> IL1t fl G`'992 '- -- -- <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Cl Distance`to nearest: Well Foundation PropertyLine <br /> 4 T <br /> SEEPAGE PITS 11 Depth Size Number t <br /> SUMPS CI Distance Ito nearest: Well Foundation._ Property Line <br /> DISPOSAL PONDS ❑ - I <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 shall not <br /> k smploy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> certifies the following: "I ce ify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> ►n laws of Californla." <br /> 'e applic t to all requ' :nape ions. Complete drawing on r as side. �^ <br /> sed Title• ZACif Date: <br /> FOR DEPARTMENT USE ONLY <br /> 3 a <br /> ►tion Accepted by Date Area, <br /> t <br /> out Inspection by Date Final Inspection by _ Date �O Z <br /> t Comments: <br /> 4 'cant - Return all copies to: San Joaq n County Public Health Services _q'��} <br /> Environmental Health Permit/Services 1 <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE� AMOUNT REMITTED CA8H RECEIVED BY DATtc PERMIT'ND. <br /> t <br />