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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, No CA 95201 a10�G p� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N Ofc <br /> (Complete in Triplicate) �`Q��� � ,� " <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application 1s 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 /> City of Size/Acreage <br /> Job Address <br /> Owner's Name Ad ess <br /> Phone <br /> ddress <br /> Contractor nee No.� Phone <br /> TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ of Service Well L)DESTRUCTION ❑ Monitoring Well <br /> PUMP STALLIO <br /> A N ❑ SYSTEM REPAIR ❑ OTHER ❑ - <br /> DISTANCE TO NEAREST: SEPTIC T K SEWER LINES DISPOSAL FLD. P OP. LINE <br /> FOUNDATIO AGRICULTURE WELL OTHER WELL ITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . <br /> n Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing <br /> [:1 Domestic/Private ❑ Gravel Pack7 ❑ Tr Type of Casing_ Specifications <br /> 1'1 Public 11 Other n Delta Depth of Grout Seal Type of Grout �C <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. Ste Work Done _ <br /> Well Destruction ❑ Well Diameter <br /> Sealing erial & Depth i <br /> Depth Filler Mater 1 & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IT- REPAIR/ADDITION I I S CTION (No septic system permitted if public sewer is ^� < <br /> ailable within 200 feet.) ' <br /> Installation will serve: Residence_ Commercial-_- Other <br /> Number of living units: Number of bedrooms yyy�' <br /> Character of soil to a depth of 3 feet: Water table depth /= <br /> SEPTIC TANK 0 Type/Mfg Capacity Compartments V!) <br /> PKG. TREATMENT PLT. ❑ Met of Disposal <br /> Distance to nearest: W Foundation Property Line <br /> LEACHING LINE C) No. & Lengthof lin Total length/size <br /> FILTER BED ❑ Distance to near t: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Dista to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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 pe a 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 al all r d in cti s. omplete dra i n rev se side. <br /> Signed X 12 <br /> e: Date.. <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by s w l® Date Z- Area d <br /> Pit or Grout Inspection by Date Final Inspection by 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 AMOUNT DUE AMOUNT REMITTED CK 8 CA RECEIVED BY TE PERMIT'NO. <br /> INFO <br /> . EH 13.2 (REV.tiN51 �,f� -7CPQ o <br /> EH 11.26 --�1 ` <br />