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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION F", ? <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED KID�Jlk `` <br /> (Complete in Triplicate) No 1� t- <br /> �IS� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work bee a is <br /> application is made in compliance with 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__SALot Size/Acreage <br /> Owner's Name &4Address Phone <br /> — � _License Nome Phone <br /> Contractor �_ Address.- � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES POSAL FLD. PROP- LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS CTION SPECIFICATIONS <br /> CI Industrial ❑ Open Bottom ❑ Manteca D' . of Well Excavation Dia. of Well Casing <br /> (:i <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing_ Specifications <br /> I'1 Public fa Other n Delta Depth of Grout Seal Type of Grout <br /> 1 i Irrigation —Approx. Depth I I Eastern Surface Sedi installed by <br /> Repair Work Done L3 Type of Pump H.P. State Work Hone r <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth T" Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I k DESTRUCTIO INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:-.,,Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: l Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ; — Method of Disposal <br /> t <br /> Distance to nearest: Wet1 Foundation ' -4 Property Line <br /> LEACHING LINE ❑ No. ✓It Length of lines -Total-length/size <br /> FILTER BED 1-J Distance to nearest: Welt Foundation Property Line <br /> SEEPAGE PITS 1 11 Depth Size Number <br /> SUMPSLl Distance to nearest: Well foundation Property Line <br /> DISPOSAL PONDS '4 ❑ <br /> I hereby certify that I have prepared Ithis 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 /> 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 /> The applicant m all for all requi insinows. Complete drawing on rev side. <br /> Signed Title: ` Date: <br /> FOR DEPARTMENT USE ONLY _ k <br /> Application Accepted by 4Q tAIA Date 7 Area 2 <br /> Pit or Grout Inspection by 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, 0 Sox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY OA PERMI1'N0. <br /> • EH 1 .21(REV.I/n 5) <br /> EH N-M <br />