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APPLICATION <br /> i <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 n_ r <br /> ' PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) h1D �a•1, � ,/ <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 /> Job Address _l` �r"s�_ Sl,� � CirJr <br /> Lot Size/Acreage <br /> r <br /> Owner's NaL Address Phone <br /> Contractor_QWKR-JR, Address _ License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 1-1 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ 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 /> n Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation Dia. of Well Casing <br /> P Domestic/Private ❑ Gravel Pack D Tracy Type of Casing— Specifications <br /> I'1 Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> l I Irrigation _Approxi Depth 1 I Eastern Surface Sedl Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction - ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I 1 DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feat.f <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 ❑ Type/Mfg' Capacity No. Compartments <br /> ~PKG. TREATMENT PET. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE El No. & Length of lines Total length/size <br /> -FILTER BED ❑ Distance to nearest: Well Foundation Property Lina <br /> ?.i <br /> i - .SEEPAGE PITS 11 Depth r Size Number <br /> SUMPS LI Distance to nearest: ' Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 4 - <br /> 1 hereby certify that I have prepared this application and that the work will be done in ac <br /> rules and regulations of the San Joaquin County cordance with San Joaquin county ordinances, state laws, and <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 shell not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 t1sofLCalifornla." <br /> Theal for I r uired inspections. mplate drawing on reverse side. <br /> }signtitre: �► Date: �a <br /> FOV,DEPARTMENT USE ONLY <br /> Application Accepted by —3d <br /> Date Area <br /> Pit or Grout Inspection by Date final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services + <br /> Environmental Health Permit/Services. <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> i FEE AMOUNT DUE AMOUNT EMITTED CK <br /> INFO RECEIVED BY 0A4 I PERMFT'NO. <br /> ��JJ ss <br /> . FH 12 (REV.I/w srszo <br /> FH 144.26 d - <br />