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APPLICATION. <br /> EI <br /> :i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 s <br /> ;j P 0 BOX 2009, STOCKTON, CA 95201 <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .(Compl.ete. in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This i <br /> application is made in coimliance with San Joaquin County Ordinance No. 549'and 1862 and the Rules and Regulations of San <br /> Joaquin County Public ealth rvices. <br /> Job Address L G1 ont City Lot Size/Acreage <br /> (AAQ Is <br /> er's Name dr (',hone <br /> Co actor dress one Jf <br /> TYPE:OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ bESTRUCTIOND Out of Service well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well o <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> �> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Oia. of;�Well,Casing <br /> omesiic/Private' ❑ Gravel Pack 0 Tracy Type of Casing_ s Specifioaiions <br /> I'I Public Cl Other f Delta Depth of Grout Seal Type of Grout <br /> M <br /> I I Irritation ' _Approx. Dept I I ante n Surface Seal Installed by <br /> Repair Work Done 0 "Type of Pump H.P.( State Work Do r o A <br /> Well Destruction ID Well Diameter Sealing Material & Depth ; <br /> k Depth Filler Material& Dijth <br /> TYPE;OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION-1-1—DESTRUCTION`I-11No"septic systemperMilted if public'sewe► is <br /> :I available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms I <br /> Character of soil to s depth of 3 feet: Water table depth <br /> SEPTIC TANK i ❑ Type/Mfg Capacity w No. Compartments _ <br /> PKG.,TREATMENT PLT. ❑ . Method of Disposal <br /> Distance to nearest: ' Well Foundation f Property Line <br /> LEACHING LINE D No. & Length of lines _ Total length/size <br /> FILTER BED 11 Distance to nearest: WeII Foundation ~- Property Line { <br /> SEEPAGE PITS I I Depth Siie" _Number <br /> 4 <br /> i <br /> SUMPS LI Distance to nearist: _ "Well'``'" - -Foundation � Property Line t <br /> DISPOSAL PONDS ❑ ' <br /> I hereby certify that I Neve prepared this7pplication and that the work will be done in accordance with San Joaquin countyjordinances, stale laws, and <br /> rules and regulations of the San Joaquin County �*- <br /> Homeowner or licensed agent.34gnature certifies the following: "I certify that Lin 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,='-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, 1 shall employ persons subjict to workman's compensa- <br /> tion laws of California' <br /> The appli t ca for all r r d in tons.ons. Complete-drawing on reverse <br /> Sig Title: Date: <br /> FOR UELARTMENTLUSE ONLY <br /> Application Accepted by�_�. �5�.�__ ` ��,,,._ _ --- Date = Area <br /> ,i <br /> Pit or Grout Inspection by- Date Final Inspection by DateZ(�A'Z <br /> Additional Comments: I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services li <br /> Environmental`Health Permit/Services' " <br /> 445 N San Joaquin, P. 0 Box 2009, Stkn, CA 95201 Z­yFEE <br /> 1` <br /> INFO AMOUNT DUE AMOUNT REMITTED CK N RECEIVED BY DATE PERMIT"NO. <br /> * EH 1 V,�ins1 D ✓/rte /r � „ <br /> EN 14.26�.2a <br /> ti � <br />