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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 Q BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 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 compliance with San Joaquin county Ordinance_No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Jab Address I r <br /> Cit Lot Size/Acreage �. <br /> Owner's Name Address I. Phone T L i <br /> Contractor I <br /> ress t_itense iVo Phone (� <br /> TYPE OF WELL/PUMP: .a MEW E L © WELL REPLACEMEN ❑ 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 Y TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of_Well Casing <br /> 11 Domestic/Private C7 Gravel Pack L1 Tracy Type of Casing_ Specifications <br /> ('I Public fa Other 171 Delta Depth of Grout Seal, Type of Grout <br /> I I Irri ation- - .ter <br /> t)" Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done_ <br /> Welt Destruction O Well Diameter Sealing Meter &I i 1) <br /> Depth Filler Material i pth \ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i RE DDITION i DESTRUCTION I i INo septic system permitted if public sewer is <br /> t available within 200 feet.) Kf <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units:11-1 Number of bedrooms <br /> Character 0f soil to a depth of 3 feet: Water table depth ' <br /> 4 <br /> SEPTIC TANK. ❑ Type/Mfg - <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 I i <br /> Method of Disposal <br /> s Distance to nearest: Well ation ¢ Property Line <br /> LEACHING LINE "Na.A Length of lines I Total length/size <br /> FILTER BED'.' /[!} Distance to nearest: Well ` Foundation Pe` Pro rtY y Line <br /> ( <br /> SEEPAGE PITS 14 Depth Size— Number <br /> SUMPS "111 Distance to nearest: Well oundation Property <br /> 'Lina <br /> DISPOSAL PONDS C1I <br /> I hereby certify that i have prepared this application and that the work will be done in accordance with Sari 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 fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> . ,k <br /> employ any person in such manner as to become subject to workman's compensation laws of California'." Contracto►'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$hall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call for all requir rn ctions. Cample a drawing on reverse side. I <br /> g r <br /> Sined Title: Date: <br /> I � <br /> FOR DEPARTMENT USE ONLY- <br /> Application <br /> NLY Application Accepted by Date Area <br /> Pit <br /> �r 3 rt <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> 5 <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 /> FEE AMOUNT DUE AMOVNT REMITTED ECEIVED BY <br /> CAK ATE PERMI7'N0. <br /> //Jf <br /> • EM 13.24MEV.Fia5t TO 1 1f <br /> EH 14•20 1� ` �� r J�ffo <br /> r- <br />