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APPLICATION <br /> )L 0,3- <br /> SAN JOAQUIN COUNTY PUBLIC HEALT S V CTs <br /> ENVIRONMENTAL HEALTH D <br /> 445 N SAN JOAQUIN, PHONE (209h4�34Z# <br /> f <br /> P O BOK 2009, STOCKTON, CA <br /> PEMIT EXPIRESYUH FROM }1._./'t/, <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work berein described. This <br /> appllcation is made in compliance with Ban Joaquin County Ordinance No. 549 end 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. /� <br /> Job Address T City Lot Size/Acreage �L� <br /> Owner's Name �� ?� D Address �� _ Phone <br /> Contractor Address License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Tl DESTRUCTION 0 Out of servlcs Wolff Cl <br /> PUMP INSTALLATION C SYSTEM REPAIR Cl OTHER 0 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPIOSAL FLD. PROP. t.INE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom Ci Manteca Dia. of Well Excavation_ ~—�— Dia. of Well C"Wwg <br /> Ll DornetticlPrivate 0 Gravel Pack 0 Tracy Type o1 Casing_ __ SpeeftAtiom <br /> I't Public Cl Other n Delta Depth of Grout Sea^ Type of Grout <br /> I I Irrigation __Approx. Depth I I Eastern Surface Said Inatolled by <br /> Repair Work Done 0 Type of Pump H.P. r _ State Work Done <br /> Wall Destruction O Well Diameter Sealing Material i Depth ,_ r <br /> Depth Filler Material ,, Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDIfIONW, DESTRUCTION 11 (No septic system permitted it public sewer Is <br /> //_ �. <br /> -available within 200 feet.) <br /> Installation will serve: Residence_L Commercial_ Other <br /> Number of living units: —.1, Number of bedrooms _ S <br /> Character of sale to a depth of 3 feet: ! Water table depth CSG! <br /> SEPTIC TANK O Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT.Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE 1K No. b Length of lines �-e "S���J/V>� To)al length/sirs <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line s _ <br /> SEEPAGE PITS I I Depth Size — Number � <br /> SUMPS Ll Distance to newest: Well Foundation Wgaertyirr <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that i have prepared this application and that the work will be doni in accordance with San.;oagtiiin county ordinances, state lawn, arid <br /> rules and regulations of the San Joaquin County <br /> Home owner or kensed agent's signature certilies the loilowing: "t cartity that in the pe,lotmence of the work to!which this permit is Issued, 1 shall trot <br /> employ any person in such manner as to become subject to workman's compensation Iowa of California,"Contractors hiring a sub-contracting signature <br /> unNbe the following:"I unify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's cornponsa- <br /> tlon taws of California," <br /> The appkcant t call for all rs fired in ctions. Complete drawing on reverse side. n <br /> Signed Title: S�r_S�� Date: <br /> K DEPAp <br /> Appkuebn Accented by Data' A <br /> Ph or Grout Inspection by Date Final Inspection by Dat✓-,�rd/ <br /> Additk"l Ctxnmonts: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> finvironmental u1n,HealP Permit2000. cea eL�QVO tW <br /> 449 N San Joaquin, P O Box 2009, 3tkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED L FtEIVED BY 0 EF <br /> INFO <br /> eH 113-24 <br /> 1324(REV.,iASI <br /> fn <br />