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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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 7� / <br /> 7 �Cv l- Of E .J' r� ��0 yLot Size/Acrea.ge <br /> Job Address City <br /> OwnerPhone's Name �' <br /> Address License No, Phone <br /> Contractor — <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT r DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER C1 Monitoring Well a <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 I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ _ Dia. of Well Casing <br /> f:l Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing— Specifications <br /> R <br /> I'1 Public I:1 Other f-1 Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation <br /> _ Approx. Depth I 1 Eastern Surface Seal installed by <br /> r { <br /> H.P. State-Work Done <br /> Repair Work Done U Type of Pump _��... , <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter <br /> Filler Material f: Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i1No septic system permitted if sewer is <br /> No <br /> vailable within 200 feet. <br /> Installation e: Residence— 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 Capac' No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well dation Property Line <br /> LEACHING LINE ❑ No. & Length of I' lengthlsize <br /> FILTER BED ❑ Distance earest: Weil Foundation ' Pro Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISP PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinancas. 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 subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica11 for all r di Clio plate drawing on reverse side. ^� <br /> /ignad Title: Date: — <br /> t/ FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> �• Date 'S 2y Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date 6'O '�� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> i Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMO NT DUE AMOU T.REMITTED � ECEIVED BY ATE PERMIT'NO. <br /> INFO <br /> cr <br /> R Y.k/K 51 r <br /> . Et;Q41 E D ( / <br /> EMN 74•Ze <br />