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f APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQIIIN, PHONE (209)468-3420 <br /> I P O BOX 2009, STOCKTON, CA 95201 <br /> l <br /> 'PERMIT EXPIRES 1 YEAR FROJA DATE ISSUED <br /> i (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 compliance-with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatio <br /> Joaquin County Public Health Services. ns of San <br /> �1 �i <br /> Job Address nom+-"' City "�"" r1 Lot Size/Acreage <br /> t�ALC�n <br /> Owner's Namef0 1NAddress _�u C ,1!' 1 <br /> os7,.` Phone 707 ,- 5�c <br /> Contractor 41/6� Address I'0 License No. Do i Phone q-31- 1 �?9 <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT nDESTRUCTIO of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring well L7 <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 /> Cl Domestic/Private ❑ Gravel Pack E) Tracy Type of Casing_ Specifications <br /> i'1 Public Cl Other fl Delta Depth of Grout Seat Type of Grout -\1 <br /> I I Irrigation _.Approx.,Dept h l I Eastern Surface Seal Installed by <br /> Repair Work Done L] Type of Pump H.P, <br /> State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Piller Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I STRUCTION I (Nc ptic system permitted if public sewer is <br /> r able 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: R 1, <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 4 Capacity No. Compartments <br /> PKG. TREATMENT PET, ❑ 1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Tota! length/size <br /> FILTER BED C7 Distance to nearest: Well Foundation Property Line <br /> 1 <br /> SEEPAGE PITS 1 ) Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i <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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature i <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 /> Tha applicant t cf aII3r ed inspections. Complete drawing on reverse side. <br /> Signed X16 Title: /111 <br /> 'Date: �o i <br /> ' FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dat;0 &�.� Aoa <br /> 2 <br /> r <br /> Pit or Grout Inspection by �f Date Final In✓pectioon bDate Additional Commen <br /> i <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> Y 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED By <br /> INFO R <br /> CASH DATE PERMIT'NO. <br /> • EH 1 <br /> 7.74tREV.tinct I <br /> EH 5476 <br /> - d <br />