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oz <br /> APDL I CATT ON FOR PERI[I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City ^4'P'�' Lot Size/Acreage <br /> Owner's Name Address oC /.�.�1�14T_ Phone <br /> t <br /> Contractor dress !21 License No. — Phone - <br /> TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O 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 <br /> El Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications v <br /> Il Public (:1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material Z Depth <br /> Depth Filler Material i Depth n <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION No septic system permitted it public sewer is f r <br /> available within 200 feet.) Y <br /> Installation will serve: Residence e 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. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line tr <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER I3ED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS CI Distance to nearest: Well Foundation Property Line r/1 <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 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 applican call for all required inspections. Complete drawing on reverse side. r <br /> Signed Title: Date: 4 6 , <br /> RTMENT USE ONLY <br /> Application Accepted by ���.� vL� --ILA boo,,_� Date ��� <br /> ©� y <br /> Ph or Grout Inspection by Date Final Inspection Date <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 INFO AMOUNT DUE AMO EMITTED CA R EIVED 84- ATE PERMIT-NO. <br /> . E14-21(REV. <br /> EN <br /> 11.26 <br />