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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ERVIRORMTAL FWALTH DIVISION <br /> 445 N SAN JOAQUIN* PHONE (209)468-3420 <br /> .� P 0 EM 2009, STOCKTON, CA 95201 <br /> (Complete in Triplicate) <br /> in <br /> a�gplicatiou is Made in cce�lance vSan �uBan Joaqin uin County O titnsnce Eo. 549 and`o2862 axed the Rules and r inatILU the vorkE ERegulationsOf Sans <br /> Jasquin Cottat7 Public Health 8e3-vicee. -7 <br /> Q r /� City y Lot Size/Acreage 7 C rG <br /> job Address (f � /�,,, 1 f <br /> J►�l V'� Adds s PO A�VOZ3 ,�,�rc�' � �ySZ Ph <br /> Darters Name -- -- <br /> Contractor <br /> i IBJ Address G,re.s Ute License No 7rJ� RZ ne <br /> TYPE OF WELL/PUMP NEW WELL O WELL REPLACEMENT n DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION ❑ SYS £ REPAIR 0 <br /> �Zi�i OTHER a Monitoring Well C]DISTANCE TO NEAREST SEPTIC TANK z� / SEWER LINES �o DISPOSAL€LD 1-70/ PROP LINE D <br /> FOUNDATION 7?Q AGRICULTURE WELL 1LO OTHER WELL C3/ PITS/SUMPS 7 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 industrial ❑ Open Bottom 0 Manteca Dia of Well Excavation Dia. of Wall Casing <br /> KDomastic/Pruvsts 0 Grit" PWk7 © Tracy Type of Casing Specificateon <br /> I 1 Public n Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Wwtiorn —Approt Depth I I Eastern Surface Seal Installed by <br /> Repan Work Done 0 Type of PumpH P Slate Done_ 1 <br /> Well Destruction ❑ Well Diameter <br /> I _ Staling Material i Depth C� <br /> GAF ,C Depth <br /> r Filler Material i Depth fi <br /> TYPE OF SEP IC WORK NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INO septic system permitted if public taewer a F <br /> available within 200 feet I <br /> 0 Installation vA serve Aes+denca_ COmin reusl_. Other <br /> Number of I ving units Number of bedrooms <br /> Character Of well to a depth of 3 feet Water table depth <br /> SEPTIC TANK ❑ TypelMfg Capacity No Comparsrnsnts <br /> PKG TREATMENT PLT 0 Method of Disposal <br /> Ditxance to nearest Well Foundation Property Leiria <br /> LEACHING LINE 0 No. 3 Length of Eines Total length/sae <br /> FILTEIR BED ❑ Distance to nesrest 10"'Wan Foundation Property Lune <br /> SEEPAGE PITS I I Depth Site Number <br /> SUMPS LI Disunce to newest VileIF�y Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> 1 hereby CsnNy that I have prepared this appkcation and that the work will be done in accordance with San Joaquin county ordinances. state laws, and <br /> rules and regtdatioris of tfte Sen Joaquin County <br /> Home owner Ot licensed ageru's tep leture comfiss the following "I cerbty that in the performsncs of the work for which this penitis a issued 1 shall not <br /> employ any person in such manner as to become subject to workman'&compensation laws of Cakfornm 'Contractors hiring or sub•contratting signature <br /> e�rsiftea the followenq h dRity that in the performm <br /> ance of the work tot which this pede:is issued.I shall employ persons subject to workman's componsa- <br /> done <br /> bwaa of CalEfomis N <br /> The apppcart newest call for all ntgwred trispectierrs Compete drawing on reverse side. <br /> 10�gp I fc _ Title- o Data a <br /> I FOR DIFPARTMEfIR USE ONLY <br /> f <br /> Akan Accepted by Area <br /> ft or Greiff Irtapeetion W Date Final� Insfpaction by Data <br /> Corrtrrierree tdditionsl ! r <br /> ' =t <br /> Applicant - Return all copies to. San Joaquin County Public Health Services <br /> 8nviromental Health PermitiServices <br /> 448 R Sao Joaquin, P O Box 3009, Stka, CA 93201 <br /> FEE CASH DUE AMOUNT REMITTEO CASH RECEIVED BY DATE PERW No <br />