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APPLICATION 3 <br /> 1'vr'• • <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 3 ENVIRONMENTAL HEALTH DIVISION <br /> p� 445 N SAN JOAQUIN, PHONE (209)468-3420 � <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 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 cotpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> Job Addrest _L _ CitySt"L4Lot Size/Acreage <br /> e <br /> Owner's Nam ► eT4Q�rr�Address . � , ,. Phone <br /> Contfacto Address Z r License W"mu�.....�Phone a<9 <br /> TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT P DESTRUCTION Out of Service Well 0 <br /> PUMP INSTALLATION C1 SYSTEM REPAIR C7 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 PR08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial C1 Open Bottom ❑ Manteca Dia. of WeII.ExcavationDia. of Well Casing <br /> Okomestic/Private Cl Gravel Pack ❑ Tracy Type-of-Casing_ VC Specifications <br /> Il Public I-1 Orther fl Delta Depth of Grout Seal Y--�� _, Type of Grout <br /> t I Irrigation31J Approx. Oep h IEastarn surface Soul Installed by ` <br /> Repair Work Done LJ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diamet r Sealing Material e, Depth T <br /> --Depth I Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I—DESTRUCTIONI I (No septic system permitted if public sewer is <br /> I. _ 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: Water table depth <br /> SEPTIC TANK. ❑ Type/Mf <br /> 9 Capacity No. Compartments <br /> • PKG. TaMethod PLT.❑ Method of Disposal <br /> Distance to nearest: Well---,Foundation Property Line <br />'f LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size w 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 eenifies 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 taws of California." Contractor's hiring or sub contra <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ g -contracting signature <br /> tion laws of California." P Y Persons subject to workman's compens!;,, <br /> The applicant tail for all uire tnspeetions. Complete drawing reverse side. <br /> Signed Title <br /> Date: <br /> PF <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by f - / C <br /> Date Area <br /> Pit o Grout spection by Date Final Inspection by Date <br /> Additional Comments: -- s ,a�� <br /> Applicant - Return all c pies to: San Joaquln County Public Health Services o <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin ox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED - <br /> 1IN.FlO �i CK CEIVED BY DATE PERMIT'NO. <br /> • EEN 13 24 H t3-24 IAEV.r i w 5i W N �� /.�C f . <br />