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SAN JOAQUIN COiTITY .' *BLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 j <br /> ; P O BOX 2009, STOCKTON, CA 95201 rl <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> This <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the wont herein described. I <br /> ith San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> application is made in Compliance w <br /> Joaquin County Public Health Services. s <br /> Citys_ — Lot Size/Acreage <br /> Job Address <br /> ` (/L Address - Phone <br /> Owner's Name �f <br /> Contractor — <br /> Address` c d License N <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well OTHER © Monitoring Well ❑(3 I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR �' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia- of Well Casing <br /> C1 Industrial <br /> El Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing_. Specifications„ <br /> Domestic/Private ❑ Gravel Pack C7 Tracy Type of Grout <br /> i'I Public to Other n Oelta Depth of Grout Seal ( , <br /> I I Irrigation —.Approx. Dap I� Eastern Surface Saul installed by a 1� Ohl <br /> H.P. State Work Done <br /> Repair Work Done L,111- Type of Pump - - Sealing Material 6 Depth <br /> Well Destruction O Well Diameter n8 <br /> Filler Material 8 Depth l l� <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I ! DESTRUCTION I I available within 200 feet.) <br /> Mo septic system ' ed �f public rawer is <br /> installation will serve: Residence,.... Commercial__,__ Other <br /> Number of living units: Number of-bedrooms a Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ,r <,. Method of Disposal <br /> Distance to nearest: Well Foundation Property`Line <br /> LEACHING LINE <br /> Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> Sire " -:'� � •- <br /> SEEPAGE PITS 11 Depth -Number <br /> SUMPS CI Distance to nearest: Wel! 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 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 of 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 C la.,, <br /> The app' nt mu call for all required in ction omplte drawing on r v aside, <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date rea. <br /> Application Accepted by A — <br /> Date Final Inspection by Date <br /> Pit or Grout inspection by 1 <br /> f - 4 <br /> Additional Comments: ` <br /> Applicant - Return all copies to; San Joaquin County Public Health S r'vices <br /> Environmental Health Permit/Sery es <br /> 445 N San Joaqui Box 20 , Stkn, CA 95201 <br /> FEE AMOUNT DUE AM UNT REW ED CK H RECEI D BY DATE PERMIT NO. <br /> INFO <br /> EK 1724(REV.' <br /> EK 1426 <br /> k <br />