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C APPLICATION *;, '� ' "° •4 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> f 445 N SAN JOAQUIN, PHONE {209}468-3420 <br /> P O BOX 2009, 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. 5149 and,1862 and the Rules and Regulations of San <br /> i Joaquin County Public Health Services. <br /> t <br /> Job Address / City '?Isati Size/Acreage <br /> Owner's Name �/ �� Address tC- �1 <br /> Phone <br /> i ContractorAddress3eS��/ � i � <br /> License N Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION .AGRICULTURE WELL - OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial f ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing <br /> '❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public Cl Other 1 n Delta Depth of Grout Seal Type of Grout <br /> t I Irrigation —Agpeox. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> .;Waft Destruction ❑ Well Diameter Sealing Material b Depth <br /> Depth Filler Material 8 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted it public sewer is <br /> • <br /> Installation will sane: Residence L� Commercial_ Other le within 200 feet.l <br /> Number of living units: Number of bedrp s <br /> LCharacter of soil to a depth of 3,feetater table depth d <br /> SEPTIC TANK. s ❑ Type/Mfg No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property tine <br /> r <br /> �r <br /> LEACHING LINE ,p,"_ - E <br /> Qamrr N0. 8 Length of tines i e'xTotal length/sire s <br /> FILTER BED C] Distance tp nearest: Wsli. <br /> �°"" "ITounda n ~- —Pioperty Lrr d 4" <br /> SEEPAGE PITS �-r'Depth a S"l" Si:e "r� <br /> "Nuiimber <br /> SUMPS LI Distance to nearest: Well 1p +i. Foundation 0 <br /> Property Lina�G <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, s <br /> rules and regulations of the San Joaquin County tate Laws, and <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit ie 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 California. <br /> "1 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 ah fo all requ"a ins ctions. Complete drawing on rev se side. <br /> t <br /> Signed X Title: '�� <br /> OAK 4 Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted py 'i <br /> �� ^- _ Date _Area, 1 <br /> / i or Grout Inspection by '2 ' 'el I -7 / <br /> C1 Finnspect`" ion by Date / <br /> Additional Comments f;" <br /> Applicant - Return all copies to: San Joaquin County Public Health Services � <br /> 'Environmental Health Permit/Serices i Y � '" <br /> 445 N San Joaquin, P O Box 2009,vStkn, CA 95201 <br /> FEE ' <br /> Of <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY <br /> + 114-28 <br /> OATE <br /> � PERMIT'NO. <br /> EM { IREV.° <br /> iZ1' 1212-7 aL <br /> d� <br />