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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES / 63 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application <br /> 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 PA41, Health Services.- <br /> Job Address =_ `� � ,._ !/ _ City Lot Size/Acreage <br /> I��1 <br /> Owner's Name : ii Address Phone <br /> Contractor Glddress. �"Y� License No.l_ 1-�7. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 1:1j:1 WELL REPLACEMENT 171 DESTRUCTION Cl out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION; AGRICULTURE WELL OTHER YVELL PITS/SUMPS <br /> INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing LL <br /> C� <br /> Domestic/Private ❑ Gravel Pack's D Tracy +' Type of Casing_ Specifications <br /> f'I Public 1-7 Other Cl Delta ` Depth of Grout Seal Type of Grout <br /> I I tioation _ Approx. Obp1p 1 1 Eastern Suace Seal Installed by <br /> Repair Work Done (z3 Type of Pump H.P. _ a / yState Work Done <br /> Well Destruction ❑ Well Diameter 1 Sealing Material & Depth <br /> Depth Filler'Material & Depth <br /> TYPE OF SEPTIC'WORK; NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is <br /> ` available within 200 feet,} ;r' <br /> installation will serve: Residence_ i'Commercial Other"' i' <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: i '- 'x Water table depth ` <br /> SEPTIC TANK. ❑ Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑, i Y r i <br /> 1 ` r- Method of Disposal <br /> Distance to nearest: Well t FoundationI iProperty Line <br /> LEACHING LINE Cl No. & Length of lines Total+length/size I <br /> FILTER BED n Distance to nearest: Well Foundation r f Property Line <br /> SEEPAGE PITS 11 Depth Size <br /> Number <br /> SUMPS Ll Distance to•nearest: Well : Foundation Property Line <br /> DISPOSAL PONDS ❑ f.. <br /> t hereby certify that I have prepared this apptication and that the w&k 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; "1 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,pertormance of the work for which this permit is issued, I shall employ persons subject to workman's compansa <br /> tion laws of California." <br /> The applicant rte call or all Seqy inspections. Complete drawing on reverse side. <br /> Signed <br /> Date: <br /> t y <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout inspection by f Date <br /> Final Inspection Date fir; <br /> Additional Comments: �. <br /> Applicant - Return all copies to: San Joaquin Ceunty Public Health Services <br /> Environmental'iHealth Permit/Services <br /> 445 N San Joaquin, P d Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'ND. <br /> INFO GASH <br /> . EH 13.21(REV. i k 51 - � <br /> EH 11.20 !r ;3 ff V <br />