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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 /> t <br /> P 0 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. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 111 Q City ze/Acreage <br /> Job Address „r„ ,DivZii& AddressPhoneOwner's Name <br /> -1�1 <br /> 1 <br /> Contractor dress License fko,�� Phone <br /> service Well 0 <br /> TYPE OF WELLIPUMP: <br /> NEW WELL ❑ WELL REPLACEMENT/L. DESTRUCTION ❑ Out of <br /> Well 7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 'I <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 /> Industrial ❑ Open Bottom C7 Manteca Dia. of Well Excavation Dia. of Weis'Casing <br /> . "r"" " Type o{Casing_ — I t Specifications <br /> Cl Domestic/Private ❑ Gravel Pack L7 Tracy <br /> I'1 Public [1 Other fl Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation w Approx. Depth l I Eastern Surface Sedi installed by` <br /> Repair Work Done 0 Type of Pump t H.P. State Work Done <br /> Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter <br /> Depth Filler Material Depth <br /> TYPE OF SEATIC WORK; NEW INSTALLATION 1 I REPAIR IADDITION DESTRUCTION i I iNo Septic system permitted'if public sewer is <br /> available within 200 feet.ia <br /> Installation will serve: Residence— Commercial Other y <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/Mig Capacity 0— No. Compartments <br /> i PKG. TREATMENT PLT. ❑ Method of Disposal ' <br /> y Distance to nearest: Well Foundation Property Line <br /> 1{� LEACHING LINE No. & Length of linesT0J@l length/size <br /> FILTER BED 0 Distance to nearest: Well � Foundation �V Property Line <br /> SEEPAGE PITS 11 Depth Size Number _ <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> rk will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the wo <br /> i rules and regulations of the San Joaquin County <br /> i 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 subcontracting 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." R <br /> The applicant mu t c I for all requi ctions. Complet drawing on reverse side. <br /> Signed X Title: � _ data: <br /> F PARTMENT USE ONLY C�2 �� R•�� <br /> Data Lk Z <br /> Application Accepted by A C.r.r. — A <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin.County Public Health Services f <br /> Environmental Health Permit/Services <br /> �} 445 N San Joaquin,,."P;O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVEdBlY DATE PERMIT"N0. <br /> INFO IL <br /> . EK 13-21(REN,1/NS) ILA <br /> t n� �1 ^lJ� <br /> EK t�•2a � <br />