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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)465-3420 4 <br /> P O BOX 2009, STOCgTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED r /� <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct "d/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address �`u l Cit Lot Size/Acreage <br /> rOwner's NameAddress Phone 7-7 <br /> t Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ onitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. OP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INT USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO <br /> Cl Industrial Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well C g. <br /> f-1 Domestic/Private Cl Grave -1 Tracy Type of Casing_. Spec ns <br /> I'1 Public C7 Other I-I Delta Type of Grout <br /> Il Ifrigation —..Approx. Depth 11 Eastern Surf eal Installed by <br /> Repair Work Done 0 Type of Pump H. State Work Done +� <br /> Well Destruction ❑ Diameter Sealing Material A Depth +C d <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I ) DESTRUCTION (No septic system permitted it public sewer 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 depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Ii Depth Size Number <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 <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, t 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 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 /> The applicant t c. u e s ion Comple drawing on reverse side. <br /> Signed Title: Date: <br /> R EPARTMENT USE.ONLY <br /> Applicstion Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by V Date Z-s —1/ <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 O Box 2009, Stkn, CA 95201 <br /> FEE CK <br /> INFO AMOUNT <br /> . EH 241pEY,1iH5� DUEAMOUNT REMITTED CASH RECEIVED BY DATE <br /> f�PERMI�T'ON0�. <br /> EH 14.2e 50 •,2f <br /> i <br /> 1�� <br />