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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> i 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> f P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EgPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 /> f Joaquin County Public Health Services. <br /> I � <br /> Job Address City Lot Size/Acreage <br /> Owner's Name Address <br /> Phone <br /> Contractor Address 0. r <br /> icense o, Phone <br /> TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMEN [7 DESTRUCTION ❑ Out of Service well ❑ �I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER C3 Monitoring Well D <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELLi <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE Of WELL PROBLEM ARE—'p STRr UG N SPECI�FiCATIO� <br /> Ll Mdustriai ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Wel! Casing <br /> Cl Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ <br /> I"I Publi I:1 Other fl Delta Depth of Grout Seal Specifications <br /> 1 rigation _....,_Approx. Dept �Iaslem Surface Seal Installed by Type of Grout <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material S-Depth _ <br /> Depth Filler Material ,L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I t INo septic system permitted it public se r is <br /> available within 200 feet.) i <br /> Installation will serve: Residence— Commercial_j Other -- {] <br /> Number of living units: ;Number of bedrooms - k <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. Water table depth <br /> ❑ 'Type/Mfg <` Capacity No. Compartments <br /> PKG. TREATMENT PLT, C1 <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ .No. & Length of lines <br /> E. Total length/size <br /> FILTER BED ID Distance'to•nearest: Well Foundation_ <br /> - Property Line <br /> SEEPAGE PITS f I Depth Sire <br /> — <br /> SUMPS Number <br /> L:l Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> J <br /> I hereby cenify 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 cenifies the following; "I certify that in the performance of the work-for which this permit is issued, I shall bot <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature <br /> certifies the following: "I certify that in t rformance of the work for which this permit is issued, I shall employ persons to workman's compensa=,' <br /> tion laws of California." ersons sub <br /> The applican m a I for all requir spec ns. complete drawing on ev se side <br /> Signed X r F <br /> Title: Data: �1• <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Z Area <br /> Pit or Grout Inspection by ,'�•�" � <br /> Final Inspection by Oats <br /> AdditionalComments: t — <br /> �pplicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health PermityServices <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE <br /> PERMIT'NO. <br />. EH 1321(1499.7/N 51r <br /> EH 14.28 -O r) `-d v <br />