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aN: <br /> :i 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. <br /> ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work be�eindescribed. This <br /> application is made in compliance with San JoaquinCounty Ordinance No. 5k and 18 2 and the Rules anegulations of San <br /> . Joaquin County Publ p wealth services. / P C�, T �f(0,4T1!W--Sysmr-f <br /> C Lot Size/Acres e <br /> - Joh Address City 8 <br /> k Owner's N8mV6—_- Address �"� Phon <br /> 04Contract ;�r Address U �1' License No. Phone <br /> TYPE OF L /P MP: il� NEW WELL ❑ WELL REPLACEMENT F.1 DESTRUCTION ❑ but of Service Well. ❑ W <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR A OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ____ <br /> f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> n Industrial ID 6pen Bottom ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing <br /> [a Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I• <br /> I'] Public 1-1 Other f] Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation ��L.Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth <br />'I TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIAODtTION i I DESTRUCTION I I INo septic system permitted if public sewer is <br /> IPI r available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other <br /> Number-of.living units: �I. Numbet'of*bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> w• <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ � - Method of Disposal <br /> Distance to nearest: "; Well Fouridation Property Line <br /> ., <br /> LEACHING LINE' L1 No. & Length of lines Total lengthtsize <br /> FILTER BED C7 Distance to nearest: Well Foundation Property Line U <br /> .Y <br /> SEEPAGE PITS l I Depth Size � Number <br /> i SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ IN <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 ficen agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued. I shall not <br /> employ any pare n i su h mariner as to became subject to workman' compensation taws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fol) i certify�that i the ante of the work r which this permit is issued, I shall employ persona subject t 'workman's compensa-1 <br /> tion laws of C <br /> i The applican s all for all If. a spectio Complete wing on reverse side. <br /> Signed Title: _ol.�//�/y Date: <br /> FO EPARTMENT USE ONLY <br /> Applicati n Accepted by Date ` Area <br /> Pit or Grout Inspection by ° Date Final Inspection by n ate Io 2� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> I� Environmental HeAlth Permit/Services <br /> I 445 N San Joaquin, P O Box '2009, Stkn, CA 95201 <br /> IF. <br /> FEE <br /> INFO AMOUtNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> I [JYF r <br /> EH14.E tAEY.r <br />