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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I 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 /> Job Address 132,0 �" i WEOET-- -- City wj(Lot Size/Acreage <br /> 13�ddress <br /> Owner's Name N Phone <br /> 7-7.0j ,A License No.�'� �7�� Phone <br /> Contractor 1 kdress `- �7 - <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Out of Service Well 0 <br /> PUMP INSTALLATION C SYSTEM REPAIR 0 OTHE p Monitoring Well e <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I-) Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fl Domestic/Private 0 Gravel Pack L1 Tracy Type of Casing_ Specifications <br /> 11 Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ...,.... Approx. Depth ( I Eastern Surface Sedi Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameter it sealing Material & Depth aFw?onl,-q _ a,PS -1; <br /> Depth Filler Material & Depth 861fem 0 &Z-AVQTiO.Y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> i <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS 1 ) Depth Size Number <br /> SUMPS 0 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 applicat ust call fo I required inspections. Complete drawing onreverseside. Z <br /> Signed Title: C / Date: —2,9 ✓ <br /> FOR DEPARTMENT USE ONLY - <br /> Application Accepted by Date �� O Area i <br /> r <br /> c <br /> Pit or Grout Inspection b ateT final Ins ection,b pati <br /> Additional Comments: a .-- <br /> Applicant - Return all copies to: San Jo 11i1 <br /> County PU16AC Heal h Sery ees <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT'N0. <br /> INFO <br /> o <br /> 00 > / <br /> EK t1.2e EVV!J <br />