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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 FAX (Z049y-6µ 0;38 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PEMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> Application is hereby made to Saxi 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 <br /> Jab Address � ' <br /> ✓ry /f V �1 City C :rt r1 Lot Size/Acreage Z f ri U0 <br /> �� <br /> ` tr, <br /> 5{'t�. 0 J r (�xvt . Address r �^'.�ie =_ J� Phone <br /> Owner aName —` --� 1 <br /> C r f' f `r cYl f j =� 'f r r PrloneJ - <br /> License <br /> Contractor �''�� 1 /r( i Address 5�� �� d No ' ` <br /> TYPE OF WELL/PUMP NEW WELL C WELL REPLACEMENT i DESTRUCTION Gi Out of Service Well Cl <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER JX Monitoring Well I7 <br /> DISTANCE TO NEAREST SEPTIC TANK S� SEWER LINES 1 DISPOSAL FLD j ''f' PROP LINE !!^ <br /> FOUNDATION •t AGRICULTURE WELL ?lf ") OTHER WELL -LC PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION_S _ Ir ,t <br /> F,f Industrial O Open Bottom C Manteca Dia of Well Excavation - Dia of Well Casing <br /> 1 L. /`� <br /> Cl Domasuc/Pnvate ❑ Gravel Pack n Tracy Type of Casing_ SWifrcatsons,t <br /> I Public ther l De <br /> ha Depth of Grout Seal _�-c fr.,-t f_ T_47Type of Grout <br /> I I Irrigdoon 1 r Approx Depth 11 Eastern Surface Sedl lnstallad by <br /> ! <br /> Repair Work Done C Type of Pump '1/ 6' H P State Work Done ? <br /> Well Destruction C Well Diameter <br /> Sealing Material i Depth <br /> t'J/, Depth E f �i�a viller Material L Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR'AODITION DESTRUCTION I I (No septic system permitted sl public sewer is <br /> available within 200 feet I <br /> Installation will oorve Residence _ Commercial — Otner <br /> Number of living units Number of bodrooms <br /> Character of Goll to a dept" 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 0 No 8 Length of Imes Total length/size <br /> FILTER BED n Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L' Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be cone 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 cdmpensa <br /> tion laws of California ' <br /> The applicant must call for sit required tnspections Complete drawing on reverse side <br /> Signed X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> • Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comments <br /> Applicant - Return all copies to San Joaquin County Public Health Services <br /> Eavironmentai Health Permit/Services <br /> $45 N San Joaquin, P O Box 2009, Stkn, CA 85201 <br /> CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE PER NO <br /> INFO <br />