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APPLICATION <br />SAN JOAQUIN COUNTY PUBLIC HE <br />ENVIRONMENTAL HEALTH DV <br />445 N SAN JOAQUIN, PHONE ( <br />P 0 BOX 2009, STOCKTON, <br />3420 <br />(Complete in Triplir4i V4V <br />#= <br />Application lar hereby made to San Joaquin County for a permit to construct nd Y 1s <br />application is tsnde in compliance with San Joaquin County Ordinance No- 51+9 and 18 2 and the Rules and Regulations of San <br />Joaquin County Public ealth Services S <br />rAddress <br />i y rc Joh Address _ JJ City Lot Siae/Acreage <br />Owner's Name --- - ,r Phone <br />477iO. <br />Contractor `ms s . �'2 - t�nse No. Phone sI r 1/ �/� j 1 <br />TYPE OF WELL/PUMP: NEW WELL'D WELL REPLACEMENT FI DESTRUCTION 17110ut of Service Well O <br />PUMP INSTALLATION C SYSTEM REPAIR Cl OTHER C7 Monitoring Well L <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ .__ DISPOSAL FLD. PROP LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />F1 Industrial <br />Cl Domestic/ Private <br />I' � Public <br />I Irriqation <br />Repair Work Done Ll <br />Well Destruction C) <br />TVPF nF WFLr <br />* Open Bottom <br />❑ Gravel Pack <br />I-1 Other <br />__ Approx. Depth <br />Type of Pump <br />WeII Diameter <br />Depth <br />PROBLEM AREA <br />CONSTRUCTION SPECIFICATIONS <br />L, Manteca <br />Dia. of Well Excavation <br />C Tracy <br />Type of Casing <br />f-1 Del;j <br />Depth of Grout Sea( <br />t I Eastern <br />Surface Seal fnsialled by <br />H P. __ <br />State Work Done <br />Sealing Material L Depth <br />�f Fille,r Mterial. i Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION <br />REPAIRIADOIT(ON i I <br />Dia. of Well Casing <br />Specifications <br />Type of Grout <br />TION I I (No septic system permated it public sewer is <br />available within 200 feet.) <br />Ins(allation will serve: Residence I— Commercial —- Diner <br />Number of living unirs: __- _ Number of bedrooms,` <br />Character of sod to a depth of 3 feet: Water table depth <br />SFP71C TANK G Type/Mfg i <br />Capacity A-12,12 Compartments <br />PKG. TREATMENT PLT, 0 Method ofisposa) . <br />Distance to nearest: Wer,/196. Foundation �� Property Line 40 <br />LEACHING LINE L� No. b Length of Imes __ Total length/size• <br />FILTER BED FJ Distance to nearest. Well Foundation __- _ Property Line <br />SEEPAGE PITS I I Depth $L�__Size �f. Number <br />SUMPS (A Distance to noa►est: Well fgo.Q� erty Foundation _ PropLine s— <br />DISPOSAL PONOS 0 sO �r <br />i hereby certify that I have prepared this application and that the work will be done in accordance with San .ioaquin county ordinances, state laws, and <br />rubs and regulations of the San Joaquin County <br />Horne owner or licensed agent's signature oenifies the following. "I certify that in the perfon-hance of the work for which this permit is issued, I shall not <br />employ any person in such mann6r as to become subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature <br />certifies the following: "I certify that in the performance of the work for which this permit Is issued, I shall ampioy persons subject to workman's compensa- <br />tion lawn of California," <br />The applicant st c fprvff req ra nspe"Clwns. Co I drawing on everse side. <br />Signed X_�i� t' _ _. Title: Date: <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by Date Lf2— •2-� ? Area t/ <br />Pit or Grout Inspection bl pate Final Inspection by S (?, _ Dete �D/- <br />Additional Comments: <br />Appl-icaut - Ret.urn all copies to; San Joaquin County Public. health Services --�� <br />Environmental Health Permit:/Services <br />445 N San Joaquin, P O Box 2009, Stkn, CA 9 i R%rro1 Q� <br />q,2.1( <br />EM 13.24 1REV. » n 5, <br />EH t4.211 <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMttTED <br />RECEIVED ByDATE <br />P <br />(z�7 <br />1r0 <br />�7,F +v83� <br />