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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 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 cotspliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ✓���j 1 <br /> -�/,,J�� f �� �DFt _ City� Lot Size/Acreage <br /> Job Address �q7 <br /> Name 'i <br /> Address _ Phone <br /> Owner's r_ PPP <br /> ContractorAddress I_D4A� License No. , Phone <br /> TYPE OF WELLIPUMP: NEW WELL D WELL REPLA MENT ❑ DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION Q�- <br /> _ _ SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES-----,DISPOSAL FLO. PROP. LINE <br /> rAGRICULTURE WELL —,OTHER WELL PITS/SUMPS J <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i <br /> C! Industrial ❑ Open Bottom C1 Manteca <br /> Dia. of Well Excavation Dia. of Well Casing I <br /> [] DomesticlPrivate ❑ Gravel Pack .0 Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other .1-I Delta Depth of Grout Seal Type of Grout I <br /> t I Irrigation _ Approx. Depth • I I Eastern Surface Sedi installed by (� <br /> Repair Work Done U Type of Pump H,P. -__ State Work Done <br /> Sealing Material i Depth <br /> Well Destruction © Well Diameter FillF <br /> er Material 8 Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION i I (No septic system permitted it public sewer is � <br /> r <br /> r available within 200 feet.) <br /> Installation will serve: Residence 4 Commercial-- Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _ �-tQe' —Water table depth <br /> T e/Mf Capacity No. Compartments `. <br />• SEPTIC TANK YP g '�t5�i <br /> PKG. TREATMENT PLT.ElMethod of Disposal <br /> Distance to nearest: Well Foundation Property Line " <br /> LEACHING LINE {1 No. & Length of lines Total len gth/size <br /> FILTER BED ❑ Distance to nearest. Well Ion 6 Foundation 22 -- Pro party Line <br /> SEEPAGE PITS Depth l¢ Siwe Number <br /> One <br /> SUMPS LI Distance to nearest: Well Foundation — Property Line _ <br /> DISPOSAL PONDS -❑ ` <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 San Joaquin County ` <br /> Home owner or licensed agent's signature certifles 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." 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." } <br /> y h <br /> The applicant must call for all r uir lnspe, ions.-Complete drawing on reverse side. <br /> Title: 6LA �� Date: <br /> Sig <br /> _R F DEPA USE ONLY r r ^ Area ®� I I ,{� <br /> T m <br /> Application Accepted y Date <br /> Pit or Grout inspection by <br /> to Final Inspection by f Date3 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services . <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT-REMITTED CASH RECEIVED By DATE PERMIT NO. <br /> INFO n <br /> . $7 <br /> EH 13-24 IACV.t i K 51 t t�� C O L 1 9'3 O <br /> EH 14-2a <br />