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ADPLICATION ,FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> f � C REMIT E%PIRES YE FRON DATE ISSU <br /> ri (Complete in Triplicate) <br /> Application Is hereby made to San Joaquin County for permit to construct and/or install the work herein described. This <br /> application in 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 <br /> ,{ <br /> Job AddressCity J Lot Size/Acreage — Y�--- <br /> Owner's Nemo ` �� RlC� Address ,✓ fes Phone <br /> { <br /> Contractors Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT DESTRUCTIOI56('Out of Service Well ❑ <br /> PUMP INSTALLATION p SYSTEM REPAIR.❑ OTHER Monitoring Monitoring Well ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK 4�— .�- 1 <br /> SEWER LINES DISPOSAL FLO.�� PROP. LINE j <br /> FOUNDATION =T 'AGRICULTURE WELL OTHER WELL , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Weil Excavationf�6_ Dia. of Well Casing <br /> 46 <br /> ,XDomestic/Private LGavel ❑ Trac TY ype of Casing_ f pecilications <br /> f'1 Public r [�cJ- n Delta Depth of Grout Seal ype of Grout <br /> I I Irrigation A . e I i Eastern Su ace Seal Installed by I <br /> Repair Work Done 0 Type of Pump `-yIYA5 H _ Stats WodqDon <br /> Well Destruction ❑ Well DiametergfSealing Material i Depth <br /> Depth 49�iller Material i Depth �•�`� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION L l DESTRUCTION I ] INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_=__ Other ] <br /> Number of+wing units: Number of bedrooms ��r <br /> Character of 001 to a depth o(3 feet: Water table depth ` : <br /> SEPTIC TANK. ❑ Type/NFfg Capacity No. Compartments Q <br /> PKG.'TREATMENT PLT.❑ <br /> w Method of Disposal ` b <br /> Distance to nearest: Well ` a Foundation Property Line <br /> LEACHING LINE' Cl No. & Length of fines'.._` _` 'Total length/site <br /> FILTER BED ❑ Distance to neaiest:, --Well Foundation_ Property Lina <br /> SEEPAGE PITS l 1 Depth Size <br /> SUMPS Ll Distance to nearest: Wel!{ �. Foundation .,�. C1 <br /> Property Line. <br /> DISPOSAL PONDS ❑ ,� <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.Josquin County ++- v»a <br /> Homs owner or licensed agent's signature,cerlifies.the following: "I certify chats n the performance of the work for which this permit is issued, l steall net <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 k <br /> certifies the following; "I certify that in the performance of the work for which this permit it issued;I shall employ persons subject to workman's compense Z <br /> tion laws of California." j <br /> The applicant -requir s.-Complete'drawing.on.re side. <br /> �, <br /> Signed <br /> Title: Date: f <br /> OR DEPARTMENT�USE ONLY- <br /> Application Accepted by 5 <br /> .���_. <br /> D <br /> _tate 3 �— Area <br /> Pit or.Grout irisMpectton by" Date i j °�^^`� Inst InSpeeci n by DateW1Z_ <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health r8e+rvices" �c,+ <br /> Environmental Health Permit/Services, _ s �J _ 1� <br /> 445-N San Joaquin, P O Box 2066, Stkn, CA 95201 <br /> 01 � � �J <br /> V ':t -1 � �. <br /> CK / <br /> �I�AftFO AMOUNT DUE AMOUNT REMITTED CASH RECtfVED BY 4 µ °DATE jPERMIT'N01 {EH 13-24IREV.1/Ktil � �,�p — r - :— i <br /> EH 14-M vim3iJ i�-3=f 2� 3ECJ <br />