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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC H� FERVICES <br /> ENVIRONMENTAL HEALTH DI (,� <br /> 445 N SAN JOAQUIN, PHONE (20$ -3420 `( <br /> P O BOX 2009, STOCKTON, CA �}}� <br /> PERMIT EXPIRES 1 YEAR FROM DAA <br /> (Complete in Triplicate) <br /> Application in hereby aside to San Joaquin County for a permit to construct andl or creln described. This <br /> application Is made In coeq,liance with San Joaquin County Ordinance No. 549 and 1062 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. e�+s A <br /> Job Address {'�t`S����✓ZC"^e �" I •`��+ Ci�ty. Lot Size/Acreage <br /> Owrri s Name or, —T , Address �. gPhone <br /> � <br /> Contracts ���—Address 7�•/_£_ _ .�icense No. Ur ` d �Tnono <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT R DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION d SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL £LD. PROP. LINE <br /> FOUNDATION _. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industnsl ❑ open Soil— ❑ Manteca Dia. of Well Exosvation, Die. of Wall Casing <br /> Cl Domastic/Privala ❑ Gravel Pack L7 Yracy Type of Casing_ Specifications <br /> I'1 Public 1-1 Other Il Delia Depth of Grout Sea! Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastem Surface Soul Installed by <br /> Repair Work Done U Type of Pump N.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AD01TlON DESTRUCTION permitted if public severer is <br /> S� faat.l <br /> Installation wail "me: Residence _ Commercial— OtherRECEIVED <br /> Number of Owing units: _ Number,of bedrooms JAN 11, <br /> Cheracter of soil to a depth of 3 test: ''�y1BYriHle depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity....p IMP (OAQ irI pCpCpp mn+b <br /> PKG. TREATMENT PLT. ❑ ENVI"RO'.'NM"ErNTTCAL 4 rl.l �y�s�N <br /> Distance to nearest: Well Foundation _ Propel IF_LrN. <br /> I <br /> LEACHING LINE No. 6 Length of lines _ Total length/airs <br /> FILTER BED ❑ Distance to nearest: Well foundation Property Line <br /> SEEPAGE PITS 11 Depth .�0—Si. /gyp Number <br /> SUMPS Distance to merest: WON fila Foundation Prepesty Lins . <br /> DISPOSAL PONDS O n SUFin PS AYN K 10 ' !Lf <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats tows, and <br /> rules and regulations of the Sen Joaquin County <br /> Home owner s licensed agent's signature unifies the following: "I cenity, that in the performance of the work for which this permits issued. I "N not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Conlractues hiring w sub-contracting signature <br /> cenities the following;"I cenity that in the psrtormance of the work for which this permit is issued. 1 shall employ persona subject to workmen's componsa <br /> tion Isom of California." <br /> The applicant uat f ma tions. Complete drowing on reverse 1�idside. <br /> Signed - Title: .�fq -_,_. ' .Data: . � (� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �� Date h Area <br /> Pit or Grout Inspection by Date FiMI Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San JoaquinCounty <br /> Health Permit/Services <br /> vices Z <br /> ooul <br /> 445 N San Joaquin, P 0 Boz 2009, Stkn, CA 95201 <br /> �'Zf NFO <br /> CHI AMOUNT DUE AMOUNT REMITTED iiA ASH RECEIVED oY TE PERMIT'NO. <br /> . TN,a.0 IeEv.near 1 /� � d011 ✓/3 /yDAf-V l / <br /> 4s {1 <br />