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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 Sea Joaquin County for a permit to construct and/or install the work herein described This <br /> application is made in compliance vith San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> Job Address 2-5 r 64, <br /> u� ` cly City ._ `C u� __ Lot Size/Acreage <br /> / <br /> ` <br /> 7 7 ; <br /> i11 Cat/ CL Address ` - Phon L' � <br /> Owner s Name <br /> Contractor Address 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 ❑ Monitoring Well O <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 /> 0 Industrial 0 Open Bottom ❑ Manteca Dia of Well Excavation Dia of Well Casing <br /> F1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I i Public I-1 Other (l Delta Depth of Grout Seal Type of Grout <br /> I I irrigation —Approx Depth I I Eastern Surface Sedi Installed by <br /> Repair Work Done 0 Type of Pump H P State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material 6 Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet 1 <br /> Installation will serve Residence_ Commercial_ Other <br /> Number of living units Number of badrooms <br /> Character of soil to o 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 8 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 /> I hereby 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 workman s compensation laws of California ' Contractor's htring or sub-contracting signature <br /> certifies the following 'I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman s compensa <br /> tion laws of California " <br /> The applicant must cal f r all required inspections Complete drawing on reverse side f 7 <br /> Signed X Title �G� "r �rJ Date C� U <br /> FOR DEPARTMENT USE ONLY /� G <br />.i <br /> Application Accepted by Date ���v' I L j Area <br /> Pit or Grout Inspectton by Date Final Inspection by Date <br /> • Additional Comments Iq <br /> Applicant - Return all copies to San Joaquin County Pub9c Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO <br /> INFO CASH <br /> h <br /> 1 n <br /> EH 13.21 iREV i/ ai <br /> EH 14 25 <br />