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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 MIRES 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 Snst:aLl the work herein described. This <br /> application is made in coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Seryl * j <br /> `1,/ , lil �xll <br /> ✓Job Address �� .rf ..__ Cir Lot Size/Acreage <br /> j,Dwnar's Namac� l�Ir1L Address Phone <br /> V Contractor OW N- __ Address_ License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION L1 Out of Service well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ Monitoring Well <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 p�; <br /> n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C.l Domestic/Private 0 Gravel Pack7 n Tracy Type of Casing_, Specifications <br /> I'1 Public (-.1 Other 11 Delta Depth of Grout Seal Type of Grout <br /> I f Irrioation __,_ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump _ H.P. State Work Done _ <br /> Well Destruction 0 Well Diameter Sealing Material A Depth p n <br /> Depth Filler Material 4 Depth �f1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTIO 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation wilt serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of sol to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg 'Capacity-- No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L1 No. & Length of lines Total length/size $ <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line ✓f <br /> SEEPAGE PITS ( I Depth Size Number F <br /> SUMPS LI Distance to nearest: Well Foundation. Property Line V <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and <br /> rules and regulations of the Sen Joaquin County <br /> Horne 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-taws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:'I c ify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss. <br /> lion laws of Califor <br /> The applicant Ifo req tion mpiete drawing on reverse side. <br /> �j <br /> r / igne ,r Title: l��/� <br /> v _ , ,,,,,......_.__ Data: <br /> 1LOR DEPARTMENT USE ONLY Q <br /> Application Accepted by A9&6 Date Area Z <br /> Pit or Grout Inspection by Date Final Inspection by Date �-7 f� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N Satz Joaquin, P O Box 2009, Sthn, CA 95201 <br /> FEE INFO A DUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATE PERMI'f'NO. <br /> + EH 13-24(hey.F/M5� <br /> EH w2s <br />