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s L � <br /> SAN JOAQUIN COUNTY PUBL_1C HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> , p O BO% 2009, STOCKTON, CA 95201 <br /> �eQ EAR FRO4 D TE I SU <br /> (Complete in Triplicate) <br /> in described. <br /> Application is hereby made to San Joaquin County for a permit to construct k anddo1662ean tall the the <br /> Rules andwork eRegul.ations of Sans <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 �+ <br /> Joaquin County Public Health services. <br /> i � Lot Size/Acreage <br /> City - <br /> Job Address 1 <br /> 3 -e � Phone <br /> /! Address <br /> Owner's Name �f� a <br /> Address <br /> act d/I a License NPnone <br /> Contractor WELL REPLACEMENT n DESTRUCTION _1 Out of a well <br /> NEW <br /> WELL C OTHER G monitoring well C] <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR' <br /> PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLO. PITS/SUMPS PROP LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �--- AGRICULTURE WELL OTHER WELL <br /> FOUNDATION " <br /> INTENDED uSE� 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - Dia. of Well Casing <br /> O Open Bottom -O Manteca Dia of Well Excavation ;�--- <br /> �ndustriel Specifications <br /> T of Casing__—_ ----- <br /> i.l Domestic/Private U Gravel Pack L:1 Tracy Type Type Te of Grout <br /> 1-1 Other n Delta Depth of Grout Seal + <br /> I"' Public Su a Seal Installed by <br /> gpprox. Dep h I I Eastern r/7 <br /> , I Irrlylauon — State Work Done <br /> Type of Pump .2�= H.P. ' <br /> Repair Work Dont Sealing Material b Depth <br /> Welt Destruction ❑ Well Diameter <br /> Filler Material b Depth <br /> Depth 1 <br /> available within 200 feet.l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I : {No septic system permitted it public sewer 1s <br /> Installation wall serve: Residence_' Commercial _ Other—�-- ` <br /> Number of living units: Number of bedrooms —Water table depth <br /> Character of s6l to a depth of 3 toot: Capacity_-- No- Compartments <br /> SEPTIC TANK O Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLY. ❑ Foundation�— Property Line <br /> "Distance to nearest:� Well <br /> .� Total length/size <br /> LEACHING LINE D.No. & Length of lutes Foundatioii Property Line <br /> FILTER BED n Oistance to nearest: Well <br /> i <br /> ''•'"Number <br /> SEEPAGE P175 11 Depth S1Ze <br /> Foundation Property Line <br /> SUMPS L` Distance to nearest: Well _­r�l <br /> DISPOSAL PONDS ❑ <br /> I hereby candy that 1 have prepared this application and that the work will be done in accordanc1. <br /> e with San Joaquin county ordinances, slate Laws, and <br /> 3- `,. v <br /> I certify that in the performance of the work for which this permit is issued, <br /> Home owner or licensed agent's signature certifies tI shell not <br /> rules and regulations of the San Joaquin Countythe fouowing: " signature <br /> employ any person in such manner as t in��become <br /> subject <br /> to the woworkman's <br /> k n's co pori$tpon laws <br /> s issued,CsI shallemploy apersons'subject 10 workman's tgcompenss <br /> certifies the following: <br /> tion Is we o1 C <br /> The ap cant must I for dl r ins tions. Complete drawing on revs side. <br /> Date: <br /> Title <br /> Signed X - <br /> R F R DEPARTMENT USE ONLY O <br /> � Date_ <br /> �. I Area <br /> Application Accepted by Date <br /> Pit or Grout Inspection by <br /> Date—..�--- Final Inspection by � <br /> Additional Comments: <br /> Public llealth Services <br /> Applicant - Return all copies to: Egviroomentaln Joaquin oHeaunty <br /> lth ermit/Services <br /> 445 N sen Joa4u1 O ox 2009, Stkn, CA 95201 <br /> CK a CEIVED BY D "E PERMIT NO. <br /> FEE AMOUNT DUE AM UNT REMITTED CASH <br /> INFO <br /> EM 13-2I IREV.tiw51 V r� <br /> EM 14-m <br />