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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 0 BOX 2009, STOCKTON, CA 95201 <br /> 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ] <br /> (Complete in Triplicate) <br /> Applicatinisfis hereby mad8 to.$itn Joaquin County far ,a perrnit to gonatruct and/or .install the work herein described. This <br /> applicatioii$IsrtBede in comtplian.e 4Philan JOttquin County 05?dinance,Ho 549 and.7862faad the Rules and Regulations of San I <br /> Joaquin Coiinty'Pti1,11c Heitlth Ser'.vices ;{{ ,4 r,� s 's9 1' J <br /> City ' Lot Size/Acreage <br /> Job Address h -- - - -- <br /> 47 <br /> Owner's Name '' � Address Phone Y' <br /> Conlrac Addred License Phon i� <br /> TYPE-Or WELL/PUMP: NEW WELL D WELL REPLACEMENT n DESTRUCTION ❑ Out of Service We11 .0 <br /> Monitoring Well 1 <br /> t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR � OTHER ❑ ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> -I - � -FOUNDATION- AGRICULTURE WELL -= --- OTHER WELL--- -. PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 industri ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Welt Casing <br /> esticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications <br /> I'1 Public f7 Other n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation Approx. Depth I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth ; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION [ I DESTRUCTION I'l (No septic system permitted i1 public sower 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:' Water table de th <br /> c <br /> - .i <br /> i <br /> SEPTIC TANK. ❑ Type/Mfg. ,.CapacityAAof�ro�iN�nta <br /> /'rY <br /> -.P <br /> PKG. TREATMENT PLT. ❑ ROVEl0sal ~� <br /> Distance to nearest: Well Foundation p l ifl8 <br /> "LEACHING LINE C1No. & Length of lines ' Total%j§Ih @ (N COUP <br /> _ 1 <br /> FILTER BED ID Distance to neares' t: Well .«.. t._.Foundatidhr ' -E!Usva� ,}� hrIGON <br /> _ ENVIRQNME�1' to ffH <br /> SEEPAGE PITS #. 11 Depth Size ^f Number <br /> " SUMPS •- - — -Ll Distance.to nearest: Well Foundation 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 iignaluie certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt 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 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 /> b. <br /> The applicant must ca ora11Yrequired'S plate drawing o averse side. �* <br /> Signe X '`' Title:�� Dateab7` r � <br /> _F R DEPARTMENT USE ONLY <br /> Application Accepted by t es �e pnarrti, -- Dale � � Area b2 <br /> rPit or Grout Inspection by Date Final Inspection bx,'f 44- WLA_,� <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 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT'NO. <br /> CASH <br /> . EH 14-II IREV.Ii w ss <br /> EH 14•2a 1 <br />