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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL g�,TH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> s��has <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br />'�oSa/ (Complete in Triplicate) <br /> application 14 hereby made to San Joaquin County for a permit to construct and <br /> Triplicate--- <br /> 'Application <br /> is made in compliance with San Joaquin County Ordinance No. 4 <br /> Joaquin County public Health Services. /or install the les herein described. This <br /> 5 9 and 1862 and the Rules and Regulations of Sen <br /> Job Address "7 5 Stu. � _ �� <br /> City Lot Size/Acreage <br /> Owner's Name6L�L r--= !�Fili Address �= c�d't �� ' <br /> 6�o ,„ <br /> ' /I'I Phone 4/ S'` p � <br /> Contractor -�UrV <br /> Address. -TYPE OF OF WELL/PUMP: NEW WELL ❑ License No. -_Phone `I6S�7/.Z <br /> PUMP INSTALLATION ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR O OTHER IdSc/ .,Monitoring Weu ❑ <br /> SEWER LINES DISPOSAL FLD. Lk�'� <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industnal ❑ Open Bottom <br /> n Domestic/Private O Manteca Oia. of Well Excavation Y" <br /> O Gravel Pack ❑ Tracy T Dia. of Well Casing <br /> f'1 Public 1-1 Other Type of Casing <br /> loatio , (l Delta Depth of Grout Seal Specifications <br /> I�Irrigacion pType of Grout <br /> Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of of pump H.P. <br /> Well Destruction Stats Work Done_ <br /> O Well Diameter �_ Sealing Material i Depth <br /> Depth %J Filler Material A Depth <br /> TYPE 0. SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system <br /> Installation will serve: R permitted it public sewer is <br /> Residence_ Commercial available within 2tb leer.) <br /> Number of living011ier <br /> units: Number of bedrooms <br /> Character of$oil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT,❑ Capacity __ No Com rt <br /> W menta <br /> Distance to nearest: WellFoundation_. Method of Disposal <br /> pro <br /> Line <br /> Party <br /> LEACHING LINE C1 No. b Length of lines <br /> FILTER BED ❑ Distance to nearest: WallTotal length/size <br /> Foundation _� Property Lins <br /> SEEPAGE PITS I I Depth <br /> SUMPS S1z° Number <br /> DISPOSAL PONDS ❑ <br /> L7 Distance to nearest: Well <br /> Foundation Property line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> rules and regulations of the San Joa uin <br /> ty <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the workfforwhich this per it is is stats laws, and <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractingsignature <br /> certifies the following: "I certify that in the performance of the work for which this Permit is issued, I shall not <br /> tan laws of California." permit is issued, 1 shall employ ug urs <br /> California.- <br /> The a P y Persons subject to workman's compensa- <br /> PPlcant st for all required���Irawingonreverse side. <br /> iSignedTitle: �o A <br /> Date: <br /> F <br />•PWiutlon Accepted by OR DEPARTMENT USE ONLY <br />'it or Grout In Date Area <br /> apection by <br /> Date Final Inspection by <br />,dditional Comments: Date <br /> Applicant - Return all copies to: San Joaquin County Publi- Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE <br /> INFO AMAMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE <br />:IREV.�ins� PERMITNO. <br /> Prr.ge 7313 <br />