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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION l <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 SanJoaquinCounty for a permit to construct and/or Install the work herein described. This <br /> application is made in compliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> cilysip Lot Size/Acreage <br /> Job Address/ <br /> Address Phone <br /> Owner's Name L f — <br /> - 1 <br /> Contractor <br /> Address ansa No. Phone <br /> of Service Well LI <br /> TYPE OF WELLIPUMP: NEW WELL LJWELL RE ACEMENT C7 DESTRUCTION ❑ Out Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CJ <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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> _ E.l Domestic/Private ❑ Gravel Pack 0 Tracy Type of CasingSpecifications <br /> _ <br /> Type of Grout <br /> Il Public 1-1 Other Cl Delta Depth of Grout Seal <br /> 11 Irrigation Approx.-Depth I 1 Eastern Surface Sedi Installed by <br /> Repair Work Done U Type of Pump / H.P. --"-"""'"'' '— State Work Done <br /> Well Destruction 19, 4 Welt Diameter 1ALW_ SesJ,-ing Material b Depth <br /> Depth Filler Material 8 Depth -d f r-P3,� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION 1 1 DESTRUCTION l,l ;No septic system permitted if public s <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ DINO 1 `- <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> Type/Mfg <br /> Capacity_"" "� No. Compartments T <br /> SEPTIC TANK <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. A Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Siie_ _ Number <br /> SUMPSt 1 Distance to nearest: Well Foundation Property Line r <br /> DISPOSAL PONDS ❑ ` <br /> I hereby certify that 1 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. I shall not <br /> k employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or suis-contracting signature <br /> i 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 /> The appli'�'us II r all raq i d ins ctions. Complete drawing on r rse side. <br /> Signed Titre: Date: <br /> F <br /> FOR DEPARTMENT USE LY <br /> Application Accepted by Date r Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <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 J/�} J L <br /> i <br /> EH 13-24(A EV,r i H.$) o, v(�' r� -1 lob -Z/. J <br /> C EH 14•Z6 <br />