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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 trade 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. <br /> Job Address o �� ��� � city -ot Size/Acreage <br /> Owner's Name �o`�`�� "" TAd cess Phone <br /> �!Contracto Addres G� License No.,`�Phone <br /> y� <br /> TYPE OF WEL /PUMP. NEW WELL 13 WELL REPLACEMENT L7 DESTRUCTION ❑ out of Service Well D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER p Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T �. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation 'Dia. of Well Casing <br /> f_7 Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ specifications <br /> I'1 Public Ll Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by $ <br /> Repair Work Done L] Type of Pump H.P. _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material 8 Depth <br /> Depth Filler Material 5 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION^ DESTRUCTION I I (No septic system permitted if public sewer is <br /> - ailable Lith-in+200 feet.l <br /> installation will serve: Residence____,'Commercial____.. Other Saaa i.. <br /> Number of living units: Number of bedrooms <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. ❑ y Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> L LEACHING-LINE 0 No. & 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 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 /> Theapplica t must call for all re uired inspections._Complete drawing on reverse side. <br /> i ered Title: � Date: S LI <br /> OR EPARTMENT USE ONLY <br /> Application Accepted by Date rsa <br /> Pit or Grout Inspection by Date Final Inspectio pate <br /> Additional Comrnenw <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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> 10 11. • <br /> i<19 <br /> 3•Z4 iREV. SIEH s O /17 V <br /> EH 74Z <br />