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h APPLICATION <br /> t <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ?c,.-.,- �e �G, a (Complete in Triplicate) „ <br /> Application is hereby rade 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. 544 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> cl;;,/ id, S2_ <br /> City � Lot Size/Acreage <br /> Job Address <br /> Address ` _ Phone <br /> Owner's Name <br /> d Address / // •J IF License No� d b Phone <br /> Contractor�' l <br /> TYPE DF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT t� DESTRUCTION ❑ Out of Service Well ❑ <br /> OTHER ❑ Monitoring Well L7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> DISPOSAL FLDPROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE Y TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. ai Well Excavation \ <br /> Type of Casing_ Specifications <br /> Cl Domestic/Private G] Gravel Pack n Tracy � Type of Grout <br /> 1'1 public 1.1 Other 11 Delta Depth of Grout Seal <br /> Irrigation Approx. De t 11 1 Ea! <br /> Surface Sea] Installed by <br /> Repair Work Done ,;A' Type of Pump �U_JLQ�r`P H•P• w 3 �] _ State Work Don <br /> '� Sealing Material & Depth <br /> Well Destruction 0Well Diameter Biller Material & Depth <br /> Depth H <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION l I arvailable wiic thin 20stem 0 fe fined it public sewer is <br /> Installation will serve: Residence^ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet:: <br /> SEPTIC TANK. i❑ Type/Mfg Capacity , No. Compsitments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. 11 Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line j <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> ' ill be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work w <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 1,1 <br /> certifies the following. 111 certify that in the performance of the work for which this permit is issued, I shall employ peraons subject to workman's compensa- <br /> tion Isws of Ca' Ia." <br /> The rcant must all for all required inspections. omplete drawing on r rse side. c <br /> Signed X Title: —^Date: 5� <br /> t <br /> F aE,27INT USE ONLY <br /> Application Accepted by <br /> f:t�ir• Date Area r <br /> F Pit or Grout Inspection by Data <br /> Final Inspection by Date r 9 <br /> L <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 /> EME[i <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> UN7.REMITTED CASH <br /> '°,� <br /> + EN 13-24 IREV.U N 5) , <br /> f EM 11.29 -•- <br />