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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> :(Complete in Triplicate) <br /> Application is hereby made•to S= Joaquin County for a permit to construct and/or install the work herein described., This <br /> application is made in comitance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage =� <br /> E <br /> Owner's Nam � Address <br /> Phontt� <br /> Contrattor � Addres ,Y� a License IVr � ,/ - --Pfione <br /> TYPE OF WELLIPUMP: NEW WELL Cl WELL REPLACEMENT Irl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ � SYSTEM REPAIR 17 <br /> OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing <br /> f7 Domestic/Private ❑ Gravel Pack t ❑ Tracy Type of Casing_ Specifications <br /> ('1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout <br /> it I Irrigation _.Approx. Depth 11 Eastern r,. Surface Seat Installed by to <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done - 1 <br /> Welt Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth CJ <br /> TYPE OF SEPTIC WORK: NEW IN 1 1 REPAIRlADDITION DESTRUCTION I I lNo septic system permitted if public sewer is <br /> r z available within 2W feet,) <br /> Installation will serve: Residence X Commercial_ Other <br /> Number of living units: L Number of bedrooms <br /> Character of soil to a depth of 3 feet:Ag /� __—Water table depth 7 2tn <br /> SEPTIC TANK1eiiii Type/Mfg Capacity No. Compartments d <br /> PKG. TREATMENT PLT. Gl " Method of Disposal [. <br /> Distance to nearest: Well Foundation Property Line <br /> # Total length/ <br /> LEACHING LINE ! No. & Length of 9 <br /> FILTER BED. ❑ Distance to nearest: Well i='+- Foundation Property Line 2492 ' <br /> SEEPAGE PITS X Depth �Size r� Number_ C- <br /> SUMPS LI Distance to nearest: Well f Foundation w +" 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 certifies the following: "I certify that in the performance'of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following. "I canify that-in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compense• <br /> tion laws of California." ' <br /> The applicant must call for all required i pecti ns.TComple drawing on reverse side. <br /> r-� Title: —� Date: 4 <br /> Signed . <br /> f <br /> I R DEPARTMENT USE ONLY <br /> A lication Accepted by <br /> Date b Area Q )L DI r <br /> Pit r Grout inspection by Date final Inspection by Date <br /> r <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 /> IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> i J O r <br /> ! Er{13-24 11111/H Sl Q � ,�� f l q D , <br />