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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 1 YEAR FROM DATE ISSUED <br /> r (Complete in Triplicate) <br /> Application is hereby made to Ban 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 Lot Size/Acreage - <br /> Job Address <br /> Phone <br /> Owner's Name <br /> Address - <br /> 3 .Xff _Phone e9 5? <br /> Contractor <br /> Lscense No <br /> Address . ^ , <br /> NEW WELL I`z WELL REPLACEMENT C; DESTRUCTION ❑ Out of Service Well ❑ <br /> TYPE OF WELL/PUMP: OTHER Lo", �n6 C7 <br /> PUMP INSTALLATION Ci C] &SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> 1 SEWER LINES DISPOSAL FLO. PROP. LINE <br /> [ 4d—ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C1 Industrial Specifications <br /> ,' Romestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> '' Type of Grout - +gym --- <br /> I'l Public Cl Other Cl Delta Depth of Grout Seal -� � ' <br /> I I Irrigation 0A Approx. Depth 11 Eastern Surface Seat installed by <br /> Repair Work Done L3 Type of Pump <br /> # .(. <br /> H,P. State Work Done <br /> i Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter ' Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I aailable loe septic system <br /> m rented if public sewer is <br /> eet.I <br /> Installation will serve: Residence TCommercial 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 ❑ Type/Mfg t Capacity No. Compartments r <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED El Distance to rnearesr. Well Foundation Property Line rQ <br /> SEEPAGE PITS 11 Depth 1 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: 111 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 ap ust call for ired inspections. Completedrawing on averse sid . <br /> Signed , <br /> Title: Date: — <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> Application Accepted by Pate �r7 r�/ �' <br /> f Date Final Inspection by Date 1/ <br /> Pit or Grout Inspection by � <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 O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> �IN�FOl <br /> �j 0 � Z- <br /> . EH 13.24IAEV.I/M-5I 5 r ©� <br /> EH 14.2E <br /> L'� <br />