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APPLICATION <br /> - SAN JOAQUIN COUNTY.PUBLIC HEALTH SERVICES <br /> ` ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN'RJOAQUIN, PHONE (209)468-3420P.-O BOB 2009, STOCKTON, CA 95201 <br /> i <br /> k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> R (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 /> t Joaquin County Public Health Services. II . <br /> Job Address � _ ��_ City hot Size/Acreage SLX f <br /> Owner's Name Na �� �h Address � <br /> one Q <br /> Contractor Address License NO. Phone <br /> TYPE OF WELL/PUM . NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PU STALLATiON 0 SYSTEM REPAIR ❑ OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELLOTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Ma Dia. - ail Excavation Dia. of Well Casing <br /> 17-1 Domestic/Private ❑ Gravel Pack Tracy Type of Casing_ Specifications <br /> C] Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I f Irrigation pprox. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well DestrY t❑ Well Diameter Sealing Material A Depth <br /> t --Depth Filter Materiel i Depth <br /> �. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIRrADDITION !'l DESTRUCTION INo septic system permitted if public sewer'is } <br /> available within 200 leet.l <br /> Installation will$erve: Residence_ Commercial— Other <br /> s Number of living units: Number of bedrooms <br /> Character of soil to a depth'!of 3 feet: t -Water table depth <br /> SEPTIC TANK. p Type/Mfg "' - ` Capacity No. Com artmen <br /> p is <br /> I PKG, TREATMENT PLT. ❑ Method of Disposal / <br /> Distance to nearesnt: Well Foundation Property Line f n <br /> l!u 11 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to <br /> �..-nearesti 'Weil Foundation Property Line <br /> i SEEPAGE PITS - E I Depth Size Number <br /> i SUMPS 11 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 K <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, !shall not - <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or mit <br /> signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ per subject ub-conman's compensa <br /> tion laws of California," <br /> The applicant ust call for all r uired inspections. Complete drawing on reverse side. <br /> j <br /> Signed Title: W/7 - - - C1 <br /> nate " . ( ' <br /> . Q <br /> . R D RTMENT USE ONLY <br /> Application Accepted by <br /> Data A L Area .l <br /> Pit or Grout Inspection by Date Final-Inspection by Date O <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 AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY <br /> CASH 1 DATE PERMIT'NO. <br /> . EH 13-I4 I1tEV.Iia 51 9 y° <br /> EH 1426 <br /> e <br />