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APPLICATION. <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN,4PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> t <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED x <br /> (Complete -in Triplicate) <br /> Application is hereby msdel`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 Rulers and Regulations of San <br /> Joaquin County Public Health Services. <br /> ` Lot Size/Acreage <br /> Job Address '� �' 'P City <br /> I <br /> Owner's Name �i Address Phone <br /> ` License No. Phone <br /> Contractor / a dress _ <br /> WELL REPLACEME T F1 DESTRUCTION Out of Service Well ❑ ' <br /> TYPE OF WELL/PUMP: I� NEW WELL ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER Q <br /> �'' DISTANCE TO NEAFtE5T-SEPTIC TANK SEWER-L-INES;; 1SPOS-At-FLOm=-�---�PROP-.-LINY— <br /> FOUNDATION AGRICULTURE.WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TY,,PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` <br /> Dia. of Well Casing <br /> p, <br /> n Bottom ❑ Manteca Dia. of Well Excavation g <br /> Cl Industrial ❑~0pe <br /> C' Domestic/Private ❑ Gfavei Pack ❑ Tracy Type of Casing_ "'Specifications <br /> i'1 Public f-1 Other f 1 Delta Depth of Grout Seal Type of Grout—-;, <br /> I i Irrigation <br /> II'Approx. Depth` i I Eastern Surface Seal Installed by <br /> 4 ' t- <br /> Repair Work Done U Type of'Pump_ _ H.P. S e k Done <br /> Sealing Material & Depth <br /> Well Destruction9 ` <br /> WeW Diameier <br /> Depth Filler Material 8 Depth <br /> TYPE OF SEPTIC WORK:•-= NEW'INSTALLATION-l•I-- REPAIRIADDITION 1,1 DESTRUCTION-[ 1 1No septic system permitted it public sewer is <br /> I! available within•200=feel.i <br /> Installation will serve: Residence Commercial,.,.,^ Other <br /> 11.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 PLT. ❑ .�� Method of Disposal <br /> Distance to nearest: Well foundation Property Line 1v II <br /> i! I <br /> LEACHING LINE D No. & Length of lines Total length/size--.. <br /> FILTER BED ❑ Distance to nearest: Wall Foundation Property Line <br /> _ SEEPAGE PITS I I Depth. .. Size Number <br /> MPS- � �1 Distance to nearest; WeeTI illation - Property Line <br /> DISPOSAL PONDS Cl �! <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 mariner 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." I� <br /> The applican st CaKfor all req spectiorts. Complete drawing on e erse side <br /> tDate: <br /> Signed Title: <br /> - II <br /> FOR DEPARTMENT USE ONLY r <br /> Application Accepted by Date --7 / Area '2,1 b <br /> Pit or Grout Inspection by V Date Final Inspection b Datttr/ Z_ <br /> Additional Comments: <br /> Applicant - Return all copies to:', San Joaquin County Public Health Services <br /> ii Environmental Health Permit/Services <br /> Ip 445 N San Joaquin,-P 0 Box 2009, 9tkn, CA 95201 <br /> ii <br /> FEE AMOUNT DUE AMOUNT REMITTED LASH RECEIVED BY DATE PERMIT'NO. .f <br /> INFO <br /> a a <br /> t . EH 17-24 IREV.I?n 51 — <br /> EH 11.26 <br />