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APPLICATION �� L 3 -- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S T/ <br /> t ENVIRONMENTAL HEALTH DIVISI <br /> 445 N SAN JOAQUIN,PHONE(209)1469- C <br /> P O BOX 388, STOCKTON,CA 95201-0 <br /> ' E_ IT IR l Y FR E IT <br /> (Complete in Triplicate <br /> ,l _—j <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.This application is made in compliance with San <br /> Joaquin County Development Title Section 9-1110.3 and Section 1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br /> Job Address rte' City 154CK1ObL Lox Size/Acreage <br /> i <br /> 1 r <br /> E Ownsr's Name Address <br /> Phone <br /> ContractorI—Q-Q�LLAddress��r�lCri License No.Z211(QLa—phone 545 +`�"r� <br /> W:; <br /> TYPE OF WELL/PUMA: NEW WELL Cl WELL REPLACEMENT Ci DESTRUCTION LI out or Service wall Q <br /> PUMP INSTALLATION OSYSTEM REPAIR.0 OTHER 0 Monitoring well fa <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER L TS/SUMPS <br /> 5 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA t� <br /> 0 industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Y of Well Casing O� <br /> C! Domestic/Private C'1 Gravel Pack n Tracy Type of Casing_ 111 U 4 r! '��ph f Well <br /> I'l Public 1-1 Other fl Delta Depth of Grout Seal ��tryI ,y�e Grout <br /> I I {riigation _Approx.'Depth t I Eastern Surface Soul Installed J"r"4 Com� <br /> Repair Work Done U Type of Pump' H.P. <br /> Well.Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth_ tiller Material i Depth <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIAOOITION I I DESTRUCTION (No septic stem f <br /> P Y permitted if public sewer is <br /> G+KovAt--. asable within 200 fest.i <br /> Insutletion will serve; Residence Commercial_ Others , <br /> Number of living unit*: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> j SEPTIC TANK q Type/Mfg Capacity— <br /> No. Co <br /> PKG."TREATMENT PLT.❑ rrtpaRrttants <br /> Method of Disposal <br /> y <br /> Distance to nearest: WON Foundation Property Line _ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED C7 Distance to nearest: Wall Founaatton property Line <br /> SEEPAGE PITS l I Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation� (� <br /> DISPOSAL PONDS p Pr°petty Line "I <br /> I hereby certify that I have preparad 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 Son,Joaquin County <br /> Homa owner or licensed agent's ppnature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Catifamia.•'Contractor's hii <br /> certifies the following:"1 certify that in the performance of the work for which this permit is issued, I shah employ bcontrocting signature <br /> tlon laws of California." P Y s wbject to man's compensa- <br /> The appli artt must call r requ' inspections. Complete drawing on reverse side. Q� 3�� <br /> Signed 4 Title: A3S,C4NL— <br /> � FOR DEPARTMENT USE ONLY <br /> I <br /> Application Accepted by — _ . Date 0 Z <br /> Area <br /> t Pit or Grout Inapaetlon by Date ,_ Final Inspection b / ,�,� Wly o(?Y <br /> � y_..`_ _ __ - ., at. <br /> Additional Commanta: S .� :, tart - ` <br /> Applicant - Return all copies to: San Joaquin County Public Health Services S£ r c � S rP <br /> �I Environmental Health /Services i ce' <br /> l 445 N.San Joaquin,P.O.O.Box 388,Stockton,CA 95201.0388 <br /> FEE AMOUNT Dllt AMOUNT REMITTED CK <br /> INFO ff H RECEIVED BY DATE PERMIT'NO. � <br /> . EM 172a IREV.tlAar �� n\O 6�yG� � <br /> EH t1.76 lJ � <br /> a <br />