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r APPLICATION O <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 /> 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. ,/1Je� <br /> Job Address �� el� City Lot Size/Acreage <br /> Owner's Named Jr/ Address -t'+i�" Phone 3 6 <br /> Contractor <br /> L Address / !?!I License No. hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION cvout of Service Well O <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES T_—DISPOSAL FLD. ROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ca Domestic/Private O Gravel Pack ❑ Tracy Type of Cajing_ Specifications <br /> I1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation a.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done Uor/Type of Pump r H.P. _�— State W Fk Doe _ <br /> Well Destruction CJ Well Diameter Sealing Material i Depth O'< <br /> Depth ��� Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is C <br /> available within 200 feet.) <br /> Installationwfli—semen esidence_ Commercial_ Other ,�— C <br /> Number of living units: umber of bedrooms <br /> Character of soil to a depth of;3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacit No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line V1\ <br /> LEACHING LINE ❑ No. & Length of Total length/size <br /> FILTER BED ❑ Distanc nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, <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 irr 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 u all for II req red inspections. Complete drawing on rever side. <br /> Signed Title: -,�Zt. Date: �" 3 <br /> n-_ ;S OR ARTMENT USE ONLY K i. <br /> Application Accepted by Ell .,� " t�d�� Date v' 3 Area <br /> Pit or Grout Inspection by Date Final Inspection by w 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 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CA$H RECEIVED BY DATE PERMIT'NO. <br /> s EN 3.24(REV.1/Na) t-� ,� t , •�- 15-WI <br /> EH 11.25 W <br />