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APPLICATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH <br />ENVIRONMENTALHEALTH DIVIM <br />445 N SAN JOAQUIN, +.# (209)4' <br />• i ti: 2009, STOCKTON, <br />(Complete in Triplicate <br />Y" <br />1; <br />iu <br />Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br />application is made in cotrtpliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br />Joaquin County Public `Heealt�h%Serv-i_cles. ( `` �y y �y <br />,-Job Address 4- `[ /" ' �V fi t%�21- rl City �� Lot Size/Acreage II U V <br />ro <br />II! <br />Owner's Name�I v�� "lr+ <br />4 412.044--t-1 Address <br />t743 I ' K' ®^� Phone <br />91'.Zo / �' ti' 7 ' . -lig <br />,Contractor <br />Address _ <br />License No. Phone <br />TYPE OF WELL/PUMP: <br />NEW WELL 0 WELL REPLACEMENT i-1 DESTRUCTION 0 Out of Service Weil <br />PUMP INSTALLATION O <br />SYSTEM REPAIR O OTHER O Monitoring Well [7 <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br />DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE <br />WELL OTHER WELL — PITS/SUMPS .._ <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA <br />CONSTRUCTION SPECIFICATIONS <br />( ) Industrial <br />❑ Open Bottom ❑ Manteca <br />Dia. of Well Excavation Dia. of Well Casing <br />C I Domestic/ Private <br />O Gravel Pack O Tracy <br />Type of Casing__ Specifications <br />I'I Public <br />Il Other lI Delta <br />Depth of Grout Seal Type of Grout <br />I I Irrigation <br />_. Approx. Depth 1 I Eastern <br />Surface Seal installed by <br />Repair Work Done U <br />Type of Pump H. P. <br />_ __ State Work Done e <br />Well Destruction O <br />Well Diameter Sealing Material i Depth <br />Depth Filler Material <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION septic system permitted it public sew <br />�IN <br />lable within 200 feet.) <br />Installation will serve: <br />Residence — Commercial _ Otlter <br />— <br />Number of living units: <br />Number of bedrooms <br />Character of soil to a depth of 3 feet: <br />star table depth <br />SEPTIC TANK <br />O Type/Mfg <br />Capacity No. Compartments <br />PKG. TREATMENT PLT. <br />O <br />Method of Disposal <br />Distance to nearest: Well <br />F ation Property Line <br />LEACHING LINE <br />L, No. 8 Length of lines <br />Total length/size <br />FILTER BED <br />n Distance to near Well <br />Foundation Property Line <br />SEEPAGE PITS <br />1 epth Size <br />Number I <br />SUMPS <br />LI Distance to nearest: Well <br />Foundation Property Line <br />)FSP ONDS <br />❑ <br />I hereby certify that I have prepared 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 San Joaquin County <br />Home owner or licensed agent's signature cartifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br />employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br />certifies the following: "I certify that in the performance of the work for which this permit is issued, I @hall employ persons subject to workman's compensa- <br />tion laws of California." <br />The appli t must call for all rel6tall ihspections. Complete drawing on reverse side. <br />Application Accepted by FOR DEPARTMENT USE ONLY Date <br />/ <br />Pit or Grout Inspection by Date Final Inspection by <br />i 1 � <br />Additional r �er..r � r�lee <br />Appl i( rrnt - Return all copies <br />San Joaquin County Public"Health Serves <br />Environmental Health pprmit/Services <br />445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br />cfp S �s.,,v4rO <br />MA <br />h <br />AMOUNT REMITTED <br />MA <br />h <br />