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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES k0A <br /> ENVIRONMENTAL HEALTH DIVISION Zce I "ORV <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> r P O BOX 2009, STOCKTON, CA 95201 S��p <br /> spry J0 ' 8 t.^ <br /> .' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;ti'rvr� 'ClC NQEAL7Cti cx,f� <br /> (Complete in Triplicate) C>�/;1�� �CTyS_r-Pv;,_5 y <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein descr bedf�/- > <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. <br /> Job Address -061 , " City_ _ Lot Size/Acreage <br /> Owner's Name Address a-!r �° �> C.4fCl PhoneV� <br /> [' c, <br /> Contractor TVC-4tf��.!2p A d s �C"Uit C�'( 5;Z-3� License No.�494 Phone eW ` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION$ SYSTEM REPAIR ❑ 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 <br /> n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications <br /> i"1 Public El Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern S%ace Seal Installed by <br /> Repair Work Done ❑ Type of Pump ;�!Iw H.P. P State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is / <br /> available within 200 feet.) <br /> Installation will serve: 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 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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 workman'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 Califo Is." r_ <br /> The applicant all for all require I tin Complete drawing o re as side. <br /> Signed X Titia: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area 2? <br /> Pit or Grout Inspection by Date Final Inspection by Date 0 <br /> ,. <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 /> INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED 8V DATE PERMfT'NO. <br /> . EH 13-24(REV.r i n 51 /'�/Y� 7 <br /> EH 14.26 III ' ` 14.E l <br />