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APPLICATION <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 to 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 Comtf Public Health Services. <br /> lob Address 04. 'yk r City 741 <br /> 6� Lot Size/Acreage <br /> Xowner's Name �MQ 1yQ 6(-)DO Address ~ I '/ Phone <br /> Contractor S ! Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E7 DESTRUCTION Cl Out of Service Well D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK S ER LI ISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM ARE ONSTRU SPECIFICATIONS <br /> n Industrial ❑ Open Bottom C Man Dia. of Well Excavati n— - Dia. of Well Casing <br /> C] Domestic/Private ❑ Gravel Pacli7 racy Type of Casing— Specifications <br /> I'l Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I ) Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P, _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTIO o septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence. Commercial_ OtherrT1 <br /> Number of living units: Ni erer of bedrooms l' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> /The applicant st call for all . d inspections. o plate drawing on r/oveer��s`i�de, f <br /> /�Signed Title: �/V`! I,+', ?,1,...__, .._. .,—__._ Date: <br /> � <br /> LIJIT� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date � Area <br /> Pit or Grout inspection by Date Pinel Inspection by A.' Date f`f <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> . EN17.24(REV.i/n5o r o66 yk?_,0SgEH 14.2E <br />