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APPLICATION SR # � � � <br /> SAN JOAQUIN COUNTY PUBLIC TsRVICES q , <br /> "Y ENVIRONM.ENTAL HEALN' <br /> 445 N SAN JOAQUIN, PHONE ( 0 a0i <br /> 3420 <br /> P O BOX 2009, STOCKTON, <br /> PERMIT EXPIRES I. YEAR R M D S <br /> (Complete in Tripli <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Pu>•ilic Health 3ervicee. ` <br /> tiCx- Lot Size/Acreage Q <br /> Job Address4 210 City <br /> Owner's Name ,r Address Phone <br /> Contractor 1hr— Addres _ j I M/Z 7 ^�-Ccense No,_.?__J` � PhonR <br /> TYPE OF WELL/PUMP: 1 6)NEW WELL ❑ w. WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION G SYSTEM REPAIR [/ OTHER b !Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES l DISPOSAL FLO PROP. LINE <br /> FOUNDATION ___ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom G Manreca Dia. of Well Excavation_ Dia. of Well Casing <br /> F? Domestic/Private Ll Gravel Pack 0 Tracy Type of Casing__—_ Specifications <br /> I"1 Public 1-1 Other 171 Delta Depth of Grout Seai Type of Grout <br /> 1 1 Irrigation Approx. Depth I 1 Easiem Suriace Seai insialled by <br /> Repair Work Done U Type of Pump H,P_ State tork Done , <br /> Well Destruction ❑ Well Diameter Sesling Material i�4i <br /> Depth <br /> Filler Material Ili r ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDIT10N r DMAWCJJ I(& ktdh►o septic system permitted if public sewer is <br /> y 11 11��`1liiCC available within 200 leet.l <br /> Installation will serve: Residenca Commercial Other__ SAN JOAQUIN <br /> Number of living units: Number a ,rooms PUBLIC HEALTH <br /> Character of soli to a depth of 3 feet_ r" ��� �T ENVIRONMENTAL HEAL 1 r; Water table depth <br /> SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Jar No, & Length of lines _ a Total length/size <br /> FILTER BED ❑ Distance to nearest: Well_J�2± Foundation + l b .-._ Property Line — <br /> SEEPAGE PITS If Depth ` Size Number <br /> SUMPS Li Distance to na+eresr. ­'iilref'_ -f- Foundation ' Pro,'erty Line <br /> DISPOSAL PONDS ❑ E <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 Son Joaquin county <br /> Home owner or licensed agent's signature certifies the following. "I certify that in the performance of the work for which this permit is issued. I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractoes hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, f shall employ persons subject to workman's compansa, <br /> lion laws of California," <br /> The applicant must all for all7rt�4bns. Comp! drawing on reverse side. <br /> Sig Title: - _ C� � _ Dale: , <br /> FOR DEPARTMENT USE ONLY <br /> Application Acceoted by �� Date Area y <br /> IPk qr Grout Inspection by rA Data Final inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> �1 445 N San Joaquin, O Box 2009, Stkn, CA 95201 <br /> Li �I IN F AMOUNT prJE /AMFEEOU REMITTED Cx RECEIVED 9Y O E PERMIT NO <br /> • EH 13.24(Arv.1/Nsr <br /> EH 14-20 / cJ <br />