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f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 20099 STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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 Regulations of San <br /> Joaquin County Public Health Services.`/ }` <br /> Job Address <br /> ` City - Lot Size/Acreage <br /> Owner's Name a� Address os - a c> Phone <br /> Contractor a Lt.)f7er,J Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT El DESTRUCTION t of Service Well CI <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r OTHER p" -Monitoring well <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 I (� <br /> 11--1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of4Well Casing <br /> [I Domestic/Private Ci Gravel Pack E7 Tracy Type of Casing_ • Specifications (� <br /> Il Public C7 Other 1-1 Delta Depth of Grout Seal Type of Grout -w <br /> 11 Irrigation —Approx. Depth 1 1 Eastern Surface Seal Installed by ` :¢ ' f I <br /> Repair Work Done ❑ Type of Pump H.P. State Work-Done <br /> Well Destruction ❑ Well Diameter Sealing Material b;Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADOI71gN I I DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.]. <br /> Installation will serve: Residence_ Commercial_ Other 'yb , <br /> Number of living units: Number of bedrooms .� <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity--- No. Compartments <br /> PKG, TREATMENT PLT. 0 'Method of Disposal <br /> i Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation d Property Line <br /> SEEPAGE PITS 11 Depth Size ANumber <br /> SUMPS LI 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 OF 1 [4 1 <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 /> empioy 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 persona subject to workman's compensa- <br /> tion laws of California." I� <br /> The applicant must tali for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> i */FOR DEPARTMENT USE ONLY <br /> p� <br /> Z <br /> I Application Accepted by � Date __ _�__ Area <br /> Pit or Grout Inspection by Date Final Inspection by A A Date <br /> Additional Comments: I J'At I <br /> Applicant; - Return all copies'to: San Joaquin County Public Health Services r/ <br /> Environmental Health Permit/Services[ i <br /> 445 N San Joaquin, ox 2009, Stkn, CA 95201 <br /> r <br /> FEF-7 <br /> MOUNT DUE AMOUNT REMITTED K ECEIVED BY DATE PERMIT'NO. <br /> INF <br /> • EM13.21IRE1r,t/ntlSpr`EH 11126 [ l <br /> 1 <br />