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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 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. f }� <br /> Xob Address710 City 41- Lot Size/Acreage <br /> Owner's Name : Address /.x . 'l Phone Ll 4A ,f?17 Z <br /> )�ConlractorAddress License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F) Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 1'i Public la Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. __ State Work Done _ J <br /> Well Destruction © Well Diameter Sealing Material 8 Depth <br /> Depth Filler Material Z Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION r-Y REPAIRIADDITION I } DESTRUCTIO o septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence v 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/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line I <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, 1 shall not <br /> employ any person in such rrtanner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 must call f r all r ired inspections. Complete drawing on reverse side. <br /> Signed = Title: 62:z Date: —// <br /> !// <br /> — 7 � <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by cm X Q Date 61(119-3 Area p <br /> Pit or Grout Inspection by Date Final Inspection by Date 1, _3 <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 INFO cA�MOUNT DUE AMOUNT REMITTED CASH'CK 9 RECEIVED BY DATE PERMIT'NO. <br /> EM 3 24 IREY.iinsr / � O _ 7 r ' 0 �t,/ G. _ <br /> 6 ` r r - -�� <br />