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I'�SApPLICATION <br /> SAN jOAQUIN COUNTY PUBLIC HEALTH oERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O 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 /> City �Q�_--- Lot Size/Acreage <br /> Job Address 57 0 zae <br /> Owner's Name ^�v " "` <br /> Phon <br /> Contractor +� !A!ltYl� ��E�s+:1`ddress � � <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPL EMENT FI DESTRUCTION ❑ Out of Service Well ❑ <br /> OTHER G Monitoring Well <br /> PUMP INSTALLATION C1SYSTEM REPAIR ❑ ��- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDs- PROP. LINE <br /> FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casin <br /> Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation <br /> C.l Domestic/Private Type of Casing Specifications <br /> Gravel Pack �7�fy 9 <br /> 1 � I{a Depth of Grout Seal Type of Grou�r!� <br /> 1'1 Public fid n� (-I OOtther <br /> I I IrripaJQn (� Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. -- State Work Done _ <br /> Well Destruction O Well Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material & Depth Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK O Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Founaation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation 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 Joaquin County <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 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 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 laws of California." <br /> The applic m st II r all requi inspections. Complete drawing on rev a side. � <br /> Signed X Title' ate: <br /> FOR QEPARTMENT USE ONLY �/ D <br /> Application Accepted by 4 !� Date Area <br /> Pit or Grout Inspection by ate 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 0 Box 2009, Stkn, CA 95201 <br /> FEE I AMOUNT DUE AMO NT REMITTED jCK5RECEIVED BY D TE PERMIT NO. <br /> INFO <br /> EH 1J-21INEV.rinui <br /> EH 1126 <br />