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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESS' � <br /> ENVIRONMENTAL HEALTH DIVISION ,{ <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCgTON, CA 95201 <br /> I <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 /> [ ti <br /> l�Job Address _� � �� �• �/� 1 City�A Lot Size/Acreage <br /> Owner's Named ? ��' w__,�Z ✓Address �L' r �% Phone <br /> Contractor J Address License No. Phone ! <br /> YPE OF WELL/PUMP" NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ll" <br /> C:7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications � <br /> I"I Public f-1 Other Cl Delta Depth of Grout Seal Type of Grout , <br /> I i Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Depth <br /> Depth Filler Material ei Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION 1 1 DESTRUCTION INo septic system permitted if public sewer is <br /> vailable within 200 feet.l <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of moil 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 <br /> LEACHING LINE ❑ No. & Length-of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> f 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 applicant Inast call f r II require Inspections. Complexe drawing on reverse side. �J /_ <br /> igned Title: ? Pl- 't�'��''y T� Date: ._ ^6/�R <br /> 1 <br /> DEPARTMENT USE ONLY <br /> Application Accepted by4QUO-_- ' Date �" �� rea <br /> Pit or Grout Inspection by Date Final Inspection Date4 <br /> Additional Comments: <br /> a <br /> I <br /> Applicant - Return all copies to; San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DtJE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT'No. <br /> . EH4314 fAEV"1/MSI q /1-L-92 ` <br />