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APPLICATION <br /> SAN (DJAQUIN COUNTY PUBLIC HEALTH !VICES pP p <br /> ENVIRONMENTAL HEALTH DIVISION ¢ <br /> 445 N SAN JOAQUIN; PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> F, <br /> Application 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 Sap Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ® 11�Addgss, City Lot Size/AcreageE.KJ.b <br /> Owner's Name MJF' ��I��Jy Address �: 2� �� n --- Phone µ <br /> Y Conttactoro Address License No. Phone <br /> YPE OF WELL/PUMP: t� NEW WELL ❑ WELL REPLACEMEtJT n DESTRUCTION Ci That of Service Well ❑ <br /> `PUMP INSTALLATION SYSTEM AIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: 'SEPTIC TANK SE R LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRI LTURE LL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C NSTRUGTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom D Manteca of Well Excavation Gia."of li�ell Casing r,.. <br /> n Domestic/Private 0 Gravel Pack ❑�' cy Type Casing Specifications <br /> I'! Public FI Other fl Dett Depth of ut Seal Type of Grout <br /> t �[� I I Irrigation i ^Approx. Depth, stein Surface'Seal Ins ed by <br /> Repair Work Done D Type of Pump H.P. tate Work Done <br /> I Well Destruction Well Diameter Sealing Material i Depth ` <br /> Depth Filler Material i Depth <br />} <br /> jr <br /> TYPE OF SEPTIC WORK: NEW iNSTALLATIO REPAIR/ADOITION f I DESTRUCTION I i INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: '.:Residence Commercial <br /> i, Number of living units: -4— Numberof bedrooms I I <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 C) t r Method of Disposal <br />+ Distance to nearest )(Well 4 oundation._ XProperty Line <br /> LEACHING LINE No. & Length'of lines Total length/size <br /> FILTER BED ❑ `Distance to nearest: Well le Foundation � !;7!- 3 Property Line Q a <br /> SEEPAGE PITS I k Depth Size Number <br /> ' + SUMPS ' Ll Distance to.nearesu Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this applicatign and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> i' 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, l 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 /> a4baJzJ1owing: "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 California." <br /> f The applic ust c r alt required inspection Comp, to drawing on reverse side. <br /> C4J N Date: <br /> Signed Title: _ <br /> S i <br /> D LY <br /> 12 Application Accepted byDate Area-12 <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 /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P ox 2009, Stkn, GA 95201 <br /> FEE AMOUNT DUE AMOUNT.REMITTED CK ECEIVED BY D TE PERMIT NO. <br /> INFO -)F / <br /> EH ti-2a CP // <br /> Qe. <br />