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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 0 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 coMliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City Lot Lot Size/Acreage <br /> Job Address ljaict <br /> Owner's Name Address L�+^,S S�►' :—I&._ Phone <br /> Contractor Address 5� - aX` . License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well C7 <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 /> C] Industrial 0 Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private 0 Gravel Pack L] Tracy Type of Casing_ Specifications <br /> I'1 Public 1-1 Other f-] Delta Depth of Grout Seal Type of Grout { - <br /> I I E,,iga,ion _Approx. Depth I i Eastern Surface Seal Installed by r ` <br /> Repair Work Done L7 Type of Pump H.P. State Work Done `"nt <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION i I DESTRUCTION INo septic system permitted if public sewer is � <br /> vailable within 200 leet.i <br /> anon wilt serve: Residence Commercial Other <br /> Number of Itvt Number of bedrooms <br /> Character of soil to a depth ater table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> i <br /> Distance to nearest: Well n Property Line <br /> LEACHING LINE Cl Na. 8 Length of lines Torsi len ze <br /> FILTER BED n Distance to n Well Foundation Property Lin <br /> ..., <br /> SEEPAGE PITS I epth Size Number <br /> SUMPSLl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL, ❑ <br /> eby 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 workmen'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 applicantust call for all required inspections. Complete drawing on reverse side. <br /> Signed " Title: I <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> Application Accepted by Date <br /> .S z.y <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> i <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 AMO NT REMITTEDRECEIVE DY E PERMIT NO. <br /> INFO <br /> . EHt3.7s ME r i w SI Uv � (Jf <br /> EH t67e <br />