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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 /> 1 P O BOX 2009, STOCKTON, CA 95201 <br /> #PERMIT E WIRES 1 YEAR FROM DATE ISSUED 'I <br /> X11 (Complete in Triplicate) <br /> made to $an: Joaquin county for a permit to construct and/or install the work herein described. This <br /> Application is hereby <br /> e in County ordinance Na. 549 and 1862 and the Rules and Eiegulations of an <br /> application is made in compliancwith San Joaqu <br /> Joaquin County Public Health Services. <br /> {I <br /> City Lot Size/AcreageIf r <br /> �6 <br /> Job Address t& <br /> .--Y Phone � <br /> I Address y <br /> Owner's Name <br /> Contractorof Service We <br /> Address License No._�.�-Phone <br /> TYPE Of WELL/PUMP: -NEW WEL ❑ WELL REPL E MENT CI•r DESTRUCTION ❑ art Monitoring Well ❑ I <br /> SYST REPAIR C1 OTHER ❑ <br /> PUMP INSTALLATION '� .,= DISPOSAL FLD. - .PROP.. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br />_ SEWER LINES PITS/SUMPS <br /> = <br /> FOUNDATION �� �— GRICULTUR WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM EA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation <br /> Cl Industrial Specifications <br /> e of Casing_ <br /> Ca Domestic/Private ❑ Gravel Pack C1 Tracy yp Type of Grout <br /> I'1 Public <br /> 1.1 Other n Delta De of Grout Seal <br /> I I Irrigation LJ Approx. Depth 11 Eas m Surf ac cal installed by <br /> H P State Work Done — Q <br /> Repair Work Done Type of Pump Sealing Material & epth <br /> Well Destruction ❑ Well Diameter Filler Material A >� <br /> Depth <br /> TYPE OF SEPTIC WOf1K: NEW INSTALLATION I 1 REPAIRlADD1TION f I DESTRUCTION I I availabe wthinNo septic s200 feet.) it public sewer is <br /> Installation will serve: Residence i Commercial Other <br /> r�n <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: 1r No, Compartments <br /> SEPTIC TANK: ❑ Type/Mfg Capacity � <br /> Method Of Disposal <br /> PKG. TREATMENT PLT. ❑• �- property Line <br /> Distance to nearest: Well.ICN2 Foundation 1 — <br /> i. Total length/size <br /> LEACHING LINE 0No. & l engtt of Ijpes-r' <br /> FILTER BED Lf.-.a stance to nearest: 'W'ell Foundation ^- Property Line SSD <br /> Sire Number r <br /> SEEPAGE PITS i I Depth,t Lam—to nearest: Wei Foundation `j property Line <br /> SUMPS Ll Distanc <br /> p11P.0SAIL PONDS ❑ <br /> t I hereby certify that I have prepared Ithis application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of theSan Joaquin County <br /> Home owner or licensed agent's sigriature certifies the following; "1 cartify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as, <br /> s to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fallowing: "!certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa <br /> tion laws of California." s `r <br /> The applicant usl call for all required ed inspections. Complete drawing on arse side. <br /> �. ` Title: Date' <br /> Signed I <br /> OR EPARTMENT USE ONLY <br /> Date ea d <br /> Application Accepted by <br /> + Pit or Grout Inspection by <br /> Date Final Inspection b Date <br /> 4& <br /> !` Additional Comments: <br /> es to: San Joaquin County Public Health Services <br /> Applicant - Return all copi <br /> Environmental Health permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> EEE CK R CEIVED Sy ATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> � EH 13.24tREV.t/K5I <br /> fH 74.26 <br />