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APPLICATION <br /> y <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH;SERVICES <br /> I` �✓ 'm4 �. ENVIRONMENTAL HEALTH DIVISION <br /> UIN PHONE 209 469-34201 <br /> 445 N SAN JOAQ ( ) , <br /> P O BOX 388, STOCKTON,CA 9526110388 <br /> ERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ENV1RONMENTALHEALT (Complete in Triplicate) <br /> l PEJ�MIT 1 SERVICES <br /> l 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 Jo <br /> . aquin County Public Health Services. <br /> II <br /> 1 1 <br /> Job AddressUJCkWAL <br /> �S Lot Size/Acreage <br /> i <br /> or IM 7 <br /> Address Phone <br /> Owner's Name <br /> Address jail C"hA I Phone <br /> Contractor - <br /> TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT 11 II DESTRUCTION ❑ 0'tt of <br /> well <br /> PUMP INSTALLATION 0 L SYSTEM REPAIR. ❑ i OTHER <br /> SEWER LINES DISPOSAL FLD. PAOP. LINE�rI <br /> DISTANCE TO NEAREST:_ SEPTIC TANK �,�- 1 n i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> ' '' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA ONS lI� <br /> I-) Industrial [I Open Bottom El Manteca Dia. of Well Excavatio I '� Dia. of 1?Vet1 CasiT <br /> Cl Domestic/Private ❑ Gravel Peck 0 Tracy Type of Casing_ Specifications <br /> I'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> Y I Irrigation <br /> _Approx. Depth I I Eastern Surface Seal Installedby I <br /> Repair Work Done U Type of Pump H.P. State Work Donq <br /> Well Destruction ❑ Wait Diameter Sealing Material i Depth M,f0 Wow <br /> _ Filler Material i Dgpth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> i; <br /> Installation will serve: Resid Commercial— Other <br /> Number of living units. Number of Wfooms �' i <br /> a <br /> Character o1 soil to pth of 3 feet: li Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Companments <br /> PKG. TREAT NT PLT.❑ <br /> ` Method of Disposal <br /> Distance to nearest: Well , Foundation PrIperty Line <br /> i <br /> LEACHING LINE Cl & Length of lines Tota] lengthlsizo <br /> FILTER BED Distance to nearest: Well Founaation Property Line <br /> SEEPAZPITSI I Depth Size NumberSUMPLI Distance to nearest: Well Foundation Property Line <br /> DISPO ❑ I <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 �� F <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 shell employ persona subject to workman's compensa• <br /> tion laws of California." I <br /> The applicen must cell for at required inspections. Complete drawing onverse side. <br /> R DEPARTM T USE ONLY q/ _ <br /> Application Accepted by Oate + `� L Area <br /> Pit or Grout Inspection by Dais Find Inspection by Data <br /> Additional Comments: it <br /> Applicant - Return all copies to: San Joaquin County Public Health Services y <br /> Environmental Health Permit/Services I� <br /> 445 N.San Joaquin,F.O.Box 388,Stockton,CA 95201-0388 <br /> l <br /> FEEAMOUNT DUE AMOUNT REMITTED GASH RECEIVED 6Y l DATE PERMIT'NO, <br /> INFO �ryL <br /> 1]-I-1;REV.1in 61 67 1 <br /> 61 12— <br /> 14-]e I a <br />