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APPLICATION <br /> fA <br /> SAN JOAQUIN COUN'1Y PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 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 xith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> / r <br /> Job Address Q�I40 e City f+ t Size/Acreage <br /> Owner's Name Q Address '® Phone / <br /> er G License No. Phone <br /> Contractor Address t^" P v �` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION Ll SYSTEM REPAIR )i� OTHER ❑ Monitoring Well C7 <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 /> L1 Industrial ❑ Open Bottom 0 Manteca Dia. of Weli Excavation Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> i'I Public (-I Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation _Approx. Oepth 1/4 Eastern Surface Seal Installed by <br /> Repair Work Done )< Type of Pump •y`^' H.P. Z State Work DoneAeA-Zoi <br /> Well Destruction ❑ Well Diameter Sealing Materiel & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if 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: x 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 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 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, 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of C ' <br /> The ap nt musLcafor all required ins tions. Complete drawing on rev er siFa. <br /> Signed X Title: __ - Date: <br /> R D PARTMENT USE ONLY 1 �` <br /> Application Accepted by 4pt, „•,,. c Dale 'f� ` �� Are <br /> (21-25 <br /> Pit or Grout inspection by Date Final Inspection bYG "` <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin Coun-ty Public Health Services <br /> Environmental Healt permit/Services <br /> 445 N San Joaquin, Box 2009, Stkn, CA 95201 <br /> I <br /> AMOUNT DUES AMO NT,REEMMITTED CA R CEIVEO 8Y DATE PERMIT'NO. <br /> . NFO <br /> EH14-24IREV.Fi�s� f�EH t�•7a <br />