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# APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � ~ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> i 445 N SAN JOAQUIN, PHONE (209)468-3420 `�a <br /> Vd ' <br /> P 0 BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EgPIRES 1 YEAR FROM DATE ISIS TT <br /> " (Complete in Triplicate <br /> Applicatioail`1s hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This ? <br /> r. <br /> application,=ia made in eoepliance with San Joaquin County Ordinance No. L <br /> Joaquin County Public Health Services. 5 9 and 1862 and the Rules and Regulations of San <br /> I <br />� --Jab Address " <br /> City Lot Size/Acreage <br /> ­"iElwner'a Name �Address <br /> �i <br /> � <br /> _ 2S <br /> ,C'ontractor Address Phone fey/ <br /> TYPE O - icense No.-PhoneEM : NE <br /> } <br /> PUMP INSTALLATION WELL ❑❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> DISTANCE TO',NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> }1 <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION ;;�____� <br /> INTENDED,USE AGRICULTURE WELL <br /> OTHER WELL , PITS/SUMPS <br /> TYPE OF WELL D <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F_1 Industrial '� ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> F:] Domestic/Private Ci Gravel Pack Dia. of Well Casing <br /> 1'I Public (A OtherC7 Tracy Type of Casing_ Specifications <br /> n Delta Depth of Grout Seal <br /> I i Irrigation I _ Approx. Depth I I EasternType of Grout <br /> Repair Work Done (] T Surface Saul Installed by <br /> Type of Pump H.P. <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material li: Depth <br /> Depth '^ Filler Material d Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i l DESTRUCTION" I (Nos <br /> lic system permit <br /> available within m I Public sewer is <br /> Installation will serve: Residence` Commercial # 0[ller__ <br /> Number of living units: Number of bedrooms <br /> Character of sAil to a depth of 3 feet: <br /> SEPTIC TANK JI 'Water.table depth <br /> ❑ Type/Mfg Capa ' ,.._ <br /> PKG. TREATMENT PLT. EllVa. Compartments <br /> Distance to nearest: Well Method of Disposal <br /> Foundation Property Line _ f <br /> LEACHING UNE ❑ No. & Length of ' " s { Y 1 <br /> FILTER BED Total length/size <br /> n Distanc nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITSI I Depth Sire <br /> SUMPS Number <br /> LI Distance to nearest: Well <br /> DISPO ONDS p Foundation. property Line <br /> reby 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 P .:: <br /> Home owner or licensed aganft signature certifies the followin <br /> em to an g: "I certify that in the performance of the work,for which this permit is issued. I shall not. <br /> P Y y 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 shall employ tion laws of California." P y Persons subject to workman's compensa• ` <br /> The applicant sl call for sit required inspe, ons. C mplete drawing on reverse side. <br /> x 5igrtad � <br /> ! Title: Date: <br /> > FOR DEPARTMENT USE ONLY i <br /> Application Accepted by , _ <br /> Date Area ,S <br /> Pit or Grout Inspection by <br /> 1 -,Final Date ,Final Inspection b Date <br /> Additional Comments: <br /> Applicant -,Return all copies to: San Joaquin County Public Health services- <br /> Environmental Health Permit/Services <br /> r 445 N San Joaquin, P p Boa 2009, Stkn, CA 95201 <br /> FEE' AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY DATE <br /> i PERMIT'N0. <br /> EH <br /> IREV, <br /> EN 14,20 <br /> a� <br />