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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br />'4 PERMIT EgPIRES 1 YEAR FROM DATE ISSUED <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 Cotopliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. i <br /> 1-}0 r City Lot Size/Acreage <br /> Job Address, -b.[^+ - <br /> Address Phone <br /> Owner's Name . <br /> Contrac Addie <br /> c3 License6&3- hon <br /> i TYPE OF WELL/PUMP: l NEW WELL 11 WELL REPLACEMENT ❑� DESTRUCTION GI Out or <br /> well G7 <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION-- :AGRICUL,TURE WELL• -__ �-Y-*0-T-HER-WELL �_P_ITSI-SUMPS-:- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Indu I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing- <br /> Type <br /> Specifications <br /> r omestic)Private ❑ Gravel Pack C1Tracy <br /> Type of Grout <br /> ( I Public t to Other fl Delta Depth of Grout Seal <br /> ` I i Irrigation AP fox. Depth I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump- H.P. State Work Done "!l) <br /> Sealing Material 3 Depth t w <br /> Well Destruction ❑ Well Diameter Piller Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION l I DESTRUCTION I I ahvaltabPerc system wilhin 200 feet.), if public sewer is <br /> { ` ! <br /> Installation WIII 59Ne Resi nce 9'* lCommercial L QtheF <_ S � S �} 1 f Y p-' N <br /> Number of living units fYu te'e of.bedfoorns <br /> ' Chatacter_of.soil to a depth of 3 feet ' ' - Water table depth <br /> ^- No. Compartments <br /> h SEPTIC TANK. ❑ Type/Mfg '��"' "„"" n-Capacity <br /> PKG. TREATMENT PLT. ❑ �._.-r-Method of Disposal <br /> t Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i .�,. - +M.r- <br /> FILTER BED ❑ Distance to nearest: Well Foundation'.�. Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS _ E1 Distance to nearest: Well _ Foundation Property Line <br /> DI5P0'SAL'PDNDS�❑ <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.sipnature certifies the following: "I cenity 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 cenity 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 /> " <br /> The applicant must II. all required inspections. Complete drawing on reverse _ <br /> Signed X <br /> Title: ] C <br /> ' I OR DEPARTMENT USE ONLY, iii E%E)EVE Q <br /> .- Date <br /> AENP1`9MEWAL <br /> eaApplication Accepted by Date Final Inspection by Date. 7 43 <br /> Pit or Grout Inspection by <br /> + Additional Comments: PERMIT SERVICES <br /> I Applicant - Return all copies to: San Joaquin Coudty Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEEEA�DUENTDUE AMOUNT REMITTED K RECEIVED BY GATE PERMIT N0.-70 <br /> INFO EH13-Y4tREV.t ! <br /> `.Eli 14.16 . <br />