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APPLICATION SR u <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH g��(7RIf � L.f <br /> $NV I RGNN�ITAL HEALTH D I V I S ���J ,__ <br /> 445 N SAN JOAQUIN, PHONE (ICAJ <br /> aw <br /> P 0 WX 2009, STOCKTON,(Complete in Triplicat <br /> Application is Hereby srtde,to San Joaquin county for a permit to construct and/or install the work bereln described. This <br /> application is sad* in compliance with Ban Joaquin County Ordinance No. 549 sad 11362 and the Rules and Reaulstions of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> • <br /> e dress // Phone <br /> Contra Addres� e4� r d icense Phon <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ out of, Service well <br /> PUMP INSTALLATION yr SYSTEM REPAIR OTHER ❑ Monitoring Yell C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑Open Bottom Ci Manteca Dia. of Wok Excavation Dim. of Wen Casing <br /> y GY1amostic/Privale ❑ Gravel Pack ❑ Tracy Type of Casing_ specific.dons <br /> I I'I Public 1'1 Other 171 Delia Depth of Grout Seal Type of Grow <br /> 1 I Irrigation N Approx. Depth I Eastern i-Surface Sedt Installed by <br /> Repair Work Done L7 m <br /> Type of Pup H.P. _ State work Dan. <br /> Wall Destruction ❑ Well Diameter SsolLag gaterial i Depth <br /> Depth Filler Material b Depth <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADOITION I i DESTRUCTION I I INo septic system permktad if <br /> pttb`C Hewer is r� <br /> f available within 200 feet,) <br /> Installation win serve_ Residence_ Commercial_ Other <br /> Number of living units. Number of bedrooms <br /> Character of sol to a depth of 3 feet: Water table depth A <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compatnrtartis f` <br /> PKG.TREATMENT PLY.❑ PAYIw1� 1 <br /> Distance to nearest: Well Foundatian <br /> LEACHING LINE Cl No. Ili Length of fines <br /> FILTER BED Q Distance to nearest: Well Foundation — ttT1CAQlnX4ft1 Iblu *rte <br /> I¢31AF iC_14FALTNSER's110ES <br /> SEEPAGE PITS I I Depth Site IMR0Aaalfl&HEALTH DIVISION <br /> SUMPS I_I Distance to nearest: Well Foundation Promm Lirw <br /> DISPOSAL PONDS ❑ <br />{ I hereby comity that I have prepared this application and that the work will be dons In accordance with San Joaquin county ordinances, ststs laws, and <br /> ruin and regulations of IM Son Joaquin County <br /> Horne owner or licensed sgant'o signature certifies the following:"i cortily that in the performance of the work for which this permit is Issued,1 shall riot <br /> ertnploY any person in such rennet as to become subject to workman's compensation Iowa of California."Contractor's hiring gr sub-eanlraetinq nipmture <br /> certifies the following:"I pltify that in the parfarmonce of the work for which this permit Is Issued.I shall employ parsons subject to workman's Compensa- <br /> tion laws of Califs <br /> The appiic I for all t opeplioru. Complete draw"on eree side. <br /> s Tide: Dow: /0 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accopoed by Date /� S'9r All <br /> Ph or Grout Inspection by Date Flrlal Inspection by- dw-1- -1r3V%ACG e� or,1 I AdJT <br /> Addidonel Comrnants: U <br /> Applicant - Return all copies to: Sao Joaquin County Public Health Services <br /> Environmental Realth Permit/8ervicea g <br /> PIS <br /> ;95 H San Joaquin, P O Box 3009, 8tkn, CA 95201FEEiNf AMOUNT Dtlti AFAOUNT��I1REMITTED CA`SH /�REC9114ED 6Y )/D!M �l"' .� ,il0 3184 !�r i{ <br /> Z.11.78 <br />