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APPLICATION C SR # <br /> SAN JOAQUIN COUNTY PUBLIC HEALTHKI S t' <br /> ENVIRONMENTAL HEALTH D I V I S I MI V l <br /> 445 N SAN JOAQUIN, PHONE (209)4 20 <br /> P O BOX 2009, STOCKTON, CA 9 C # <br /> PERMIT EXPIRES 1 YEAR FROM DATE <br /> (Complete in Triplicate) <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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> -Z?�2V t 4 t City �--� Lot Size/Acreage <br /> Job Address <br /> Owner's Name <br /> Address T(f�(f�T� Ly r vim' � A-) I Phone , �U <br /> f�C`onUaclor <br /> �1���✓�`� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 13WELL REPLACEMENT Cl DES RUCTI N ❑ Out of Service Well <br /> SYSTEM REPAIR El ER Monitorl ell ❑ <br /> PUMP INSTALLATION ❑ / Gk/s�tt <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing-.---- Specifications <br /> I'1 Public (1 Other 11 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation p[. th 11 Eastern S rface Seal Installed by <br /> _ Type State Work Done <br /> Repair Work Done LN' 1 of Pump �. (� H.P. --- <br /> 1% Sealing Material i Depth <br /> Well Destruction O Well Diameter , <br /> Depth - Filler Material i Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I INailabetic sysshit m rented if public sewer is <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 O 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 Cl Distance to nearest: Well _ Founaatron Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> 411aws, an <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stat <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 C iforni " <br /> kThe applicant u call r all r fired inspections. Complete drawing on reverse side. <br /> ed X % Title: U�� �e—Md� Date: / L <br /> FOR PARTMENT USE ONLY O�� <br /> _Ckf. <br /> Date �+� Area <br /> Application Accepted by <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> z 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> j�� FEE AMOU�DUEAMOUNT REMITTED CASH RECEIVECK iD BV DATE W9PERMIT NO. <br /> �j INFO rEM t}24(REV.tiaef111 , <br /> EM 74.26 - 7 <br />