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3 <br /> it <br /> 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, CA 95201 <br /> ` 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 14 air (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 1s made in compliance with San Joa uin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County bli Health Services. TL <br /> 4&w4tt <br /> Size/Acreage <br /> Job Address <br /> Phone <br /> Owner's Name Address <br /> Phone <br /> Contractor ddress r <br /> i se No. <br /> NEW ELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well O <br /> TYPE OF WELL/PUMP: THEFJ O Monitoring Well ❑ <br /> _ UMP INSTALLATION O / SYS EMR AIR ____ _ <br /> DISTANCE TO NEAREST: SEPTIC TANK - <br /> SEWER LINES DISPOSAL FLD ROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS /r <br /> INTENDED USE TYP OF WELL PROBLEM AREA CONSTRUCTION SPECIE ATmr N!�� f <br /> C! In nal pen Bottom ❑ Manteca Dia. of Well Excava ion <br /> Dia. of Well Casing - <br /> Type of Casing_ Specifications <br /> omestic/Private O Gravel Pack ❑ Tracy Tye of Grout <br /> I'I Public EI Other n Delta Depth of Grout Seal <br /> I I Irrigation Approx. De I I astern ?urfaee Seal Installed by <br /> Repair Work Done U Type of Pump <br /> H P _ State Work Done— <br /> Well Destruction O Well Diameter of 3ea11 Ma erial & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW T LATION I 1 REPAIR/ADDITION I I DESTRUCTION I I alvailablerw thin 200 feet.)stem ited it public sewer is <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK O Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. O f <br /> Distance to nearest: Well Foundation Property Line <br /> ----------------- <br /> LEACHING LINE O No. & Length of lines <br /> Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS.`. 11 Depth -Size�— <br /> Number <br /> SUMPS LI Distance to nearest: �Weih Foundation Property Line <br /> DISPOSAL PONDS O <br /> hat the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that 1 have prepared this application and t <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 rformance 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 m call for all r quired ' ctio Complete drawing on r se side <br /> Signed X Title: <br /> Date: / <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date � ya�_ Z" Area <br /> Pit or et <br /> Inspection-by <br /> a e < net Inspection by �� � �� ate�-�L3 <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 R CEIVED BY TE PERMIT'N0. <br /> INFO AMOUNT DUE AMOUNT REMITTED CA J7Ji <br /> . EH 13.21 IREV.I/n 51 ` <br /> EH 11.26 <br />