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APPLICATION ' <br /> G - 3� - <br /> SAN JOAQUIN COUNTY PUBLIC HEAL . ES <br /> ENVIRONMENTAL HEALTH DIV <br /> (6 kv 445 N SAN JOAQUIN,PHONE(209) 6� <br /> P O BOX 388,STOCKTON,CA 952 1- <br /> PRUIT EXPIRES 1 YEAR FROM SIIED Lb [3 7 <br /> (Complete in Triplic <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.This application is made in compliance with San <br /> Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br /> Job Address ` . City Lot Size/Acreage/ f <br /> Owner's Name Address Phone <br /> Contractor Address /0::sLicense No. Phonefy <br /> 3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Yell ❑ <br /> PUMP INSTALLATION 'G 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 /> ❑ Industrial O Open Bottom 0Manteca Dia. of Well ExcavatPAYMENT— Dia, of Well Casing <br /> Ia Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I'1 Public 1-1 Other f) Delta Depth of Grout Seal <br /> Type of Grout <br /> I i IrrigationAppro><. Depth I !_Eastern -Surface Seal Install-H <br /> Repair Work Done U Type of Pump H.P. I C WT1 <br /> Well Destruction ❑ Well Diameter Seali'n8 Material 4 ES" <br /> Depth Filler Dfaterial MEIVTAL HEALTH I31Y1 N <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCT- <br /> I t 1No septic system permitted if public sewer is <br /> available within 200 fset.l <br /> Installation,Aill serve: Residence Commercial Other <br /> Number of'fiving units: _,,.,L- Number of bedrooms <br /> i <br /> Character of sod to:a depth of 3 feet: Water table depth <br /> SEPTIC TANK D Typo/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE. No. b Length of lines' q Q Total length/size <br /> FILTER BED C1 Distance to nearest: Well _' FouncI tion �� Property Line -(� •— <br /> SEEPAGE PITS Depth Number <br /> SUMPS Ll Distance to nearest: Well�L „ Foundation;,,!,�M f Property fine S� <br /> DISPOSAL PONDS 0 ; <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 taws, 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."Contractors 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 California." <br /> The applicant at eel or all r wired inspections. Complete drawing on reverse side. <br /> Signed zz. Title.• w <br /> Date: <br /> 1 FOR DEPARTMENT USE ONLY <br /> Application Accepted by (VI•` Z 2 <br /> Date ea <br /> Pit or Grout Inspection by Rate final Inspection b ` Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services I <br /> 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 <br /> FEE AMOUNT DUE AMOUNT REMITTED C� RECEIVED BY DATE PERMIT'N0. <br /> t C/ INFO CASH <br /> EH 13-24 <br /> • E!i 1 .36 iRIN.iiwsi a <br />