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APPLICATION <br /> P'EICKETT'S PUMP& WELL SERVICbAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> P.O. BOX602 LINDEN, CA 95236 ENVIRONMENTAL HEALTH DIVISION <br /> CONT. . #521666{209)944-5969 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 /> i <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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> Job Address -- ♦ J � C C <br /> City__„� � t Size/Acreage III <br /> Owner's NBnAA A �rCyi Address &q W,_0 _ Phone V7 <br /> P.O. BOX 602 LINDEN, CA D016 <br /> Contractor •`%N%,, License No. Phone f� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT R DESTRUCTION C1 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR A4 OTHER ❑ Monitoring Well ❑ 1 <br /> `DISTANCE=TO­NEAREST,-SEPTIC SEWER-LAN ES- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ;*Domestic/Private ❑ Gravel Pack7 L1 Tracy Type of Casing_ Specifications <br /> UI Public 1-1 Other Cl Delta Depth of Grout Seat Type of Grout <br /> I # Irrigation — Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump _ 4,� _ H,p, JA S State Work Done dJ .. <br /> Well Destruction Well Diameter — Sealing Material & Depth <br /> Depth 7. Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION 1 I DESTRUCTION I I IN,) septic system permitted it public sewer is <br /> available within 200 feel.1 <br /> LN <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�abpe <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. �� 1 pe, <br /> PKG. TREATMENT PLT, ❑ � Mel" Qs `-^ <br /> Distance to nearest: Well Foundation Property Li.._ ` r <br /> SAN JOA UIN COUNTY <br /> LEACHING LINE ❑ No. & Length of lines Total len LIC HEALTH SERVICES <br /> FILTER BED ❑ Distance to nearest: Well Foundation Pi., I Ins <br /> N <br /> SEEPAGE PITS ISI .Depth _ 5i:e _ Number. <br /> Y SUMPS Cl 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: "1 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 m t tail for all requ"d inspictions. Complete drawing on reverse side. <br /> Signed X <br /> Title: N _ <br /> Date: <br /> A — <br /> FDWIDEP M LY <br /> Application Accepted by O7 <br /> Date ea <br /> Pit or Grout Inspection by .Date Final Inspection b Data y <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 AMOUNT DUE AMOUNT REMITTED <br /> IN <br /> FO CK RECEIVED BY DATE PERMITNO. <br /> + EH 13.24{REV,i/HSS <br /> EH 14,10 *JOrr <br />