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APPLICATION S <br /> UIN COUNTY PUBLIC HEAL S&RV <br /> SAN JQ I Ts <br /> OA <br /> HNYIRON11ENTAL HEALTH DIY <br /> 445 X SAN JOAQUIN, PHONE (20 SRAMd <br /> P O BOX 2009, STOCKTON, C Pt1O# <br /> PERMIT EXPIRES 1 YEM E90—M D '�3� <br /> (Complete in Triplica <br /> .kation is hereby made•to Ban Joaquin County .for a permit to construct and/or instralI the work herein described. This <br /> kation in mede:in compliance with San Joaquin County Ordinance No. 549 and 1862%nd the Rules and Regu)ations of San <br /> loin County Publie,Health.Services. <br /> Address <br /> + ►A✓I�-= City Lot Size/Acreage <br /> ._ tt <br /> LAo <br /> er's N <br /> Address 1 Phone <br /> C racl Address �i�.Rcrk :z67 License No. ZZ r?Phone (v9-s <br /> E OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Q <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O monitoring Well ❑ <br /> rANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �. . <br /> NTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Wustrial O Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Wed Casing. <br /> lomestWPrivate 0 Gravel Pack ❑ Tracy Type of Casing <br /> i�bdc !:1 Other n pelta Depth of Grout Seal ILt <br /> ngation Approx. Depth 1 ! Eastern Surface Seal installed by - <br /> Itir Worms Done ❑ Type of Pump H.P. State Work DCA <br /> I DestructionClWell Diameter Sealing Material i Depth - <br /> Depth Filler Material i Depth <br /> iE OF SEPTIC WORK:; NEWINSTA TION REPAIR/ADOITlt?N i ! DESTRUCTION I I �rt� }2W feet.) <br /> stallation v4 serve: Residence Commercial-___ cher <br /> umber of living units:__L__ Number ofooms O <br /> hamster of sod to a depth of 3 feet: Water table depth <br /> TIC TANK- Typo/Mfg Capacity No.'Compartments <br /> ).'TREATMENT PLT.❑ Method of Disposal <br /> r Distance to nearest- . .-Well _ Foundation !6+ _ Property Lim <br /> CK1146 LINE No. a Length of lines tlQ TOM fatigth/sit. <br /> fER BED 0 Distance to nearest: Weil Foundation- '- Property line A -h <br /> fi <br /> 'PAGE PITS Depth Size f�fumtisr <br /> MPS LI Distance to nearest_ Wed�QD Foundation ,.��fi Property Lin. <br /> POSAL PONDS ❑ <br /> rreby certify that 1 haus prepared this application and that the work will be done in accordance with San-Joaquin county ordinances, state laws, and <br /> to and regulations of the San Joaquin County Z <br /> m owner or licensed agents signature conifros the following:"I certify that in the performance of the work foi which this permit isissued, I shad not <br /> cloy any person in such maturer as to become subject to workman's compensation laws of Calitarnia."Contractor's hiring or sub-contracting signature <br /> Iffres the folbwing:"I certify that in the performance of the work for which this permit is issued,i shall employ persons subject to workman's componsa- <br /> I laws of California.*' <br /> I applicant st troll for ire 'nspections. Complete drawing on reverse side. r <br /> nod Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> plication Accepted by Dat. Arse <br /> or Grout fnspectlon by to- r final Inspection by Da <br /> ditional Comments: <br /> Applicant - Return all copies to: San Joaquin Country Public Health Services <br /> Environmental Health Permit ervices <br /> 1 445 N San Joaquin 009, Stkn, CA 95201 <br /> t <br /> UFEf <br /> AMOUNT DUE AMOUNT.REMITTED NECENED BY TE PERMIT•NO. <br /> IgEY.1 <br />