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APPLICATION <br /> "R # <br /> SAN JOAQUIN COUNTY PUBLIC HEALTIA SERVICES <br /> ENVIRONMENTAL HEALTH DIVISI64 <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 5201'; I <br /> PERMIT EXPIRES 1 YEAR FROM DA E ISSIPED D 1 D <br /> (Complete in Triplicat }--- <br /> Application is hereby msde,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 end Regulations of San <br /> Joaquin County <br /> lPublic <br /> /Health Services. <br /> Job Address r/ r�` & 4, � ����=� — City Lot Size/Acreage <br /> � -TT— <br /> Owner's Name j �/ \ �— Address Phone <br /> Contractor Address L4cense <br /> TYPE OF WELL/PUMP NM WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENpED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> t"1 Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications <br /> I.1 Public 1-1 Other P Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump N.P. ___ State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth ` t <br /> Depth Filler Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Wither <br /> Number of living units: 4- Number of bedrooms <br /> Character of soil to a depth of 3 feet- �w Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity f 7e� No. Compartments <br /> PKG. TREATMENT PLT. O Method of Dispose <br /> Distance to nearest: Well Foundation Property Line <br /> nl <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ( I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 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 applica�st call for all q fired inspections. Complete drawing on reverse side. <br /> Signed X ice- ��-� Title: Date: <br /> • FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 0 ` Area <br /> Pit or Grout Inspection by / Date Final Inspection by ^ ate <br /> Additional Comments: OU C6 Ps <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> q2 * <br /> / ` 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> "TZ ' �` FEE MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO/i / / �) CASH <br /> . EM 13-24(REV.rins �/ �- [' ✓ /'d.S-j.-� �-V 6 f V 1 <br /> EH 14-26 <br />