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SAN JOAQUIN COUNTY PUBLIr HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br />{ 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> k I P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> J (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 /> c <br /> Job Address `' t 4 City� Lot Size/Acreage <br /> Owner's Name Address 2 _ Phare <br /> Contractor Address d vt cense No 6 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION Cl Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRAI OTHER C1 Monitoring Well <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 /> n Industrial ❑ Open-Bottoin ❑ Manteca Dia. of,Well Excavation Dia. of Well.Casing <br /> �Q Domestic/Private.--. Cl Gravel Pack T,_❑ Tracy Type of Casing , Specifications <br /> I'I Public l_1 Other (l Delta Depth of Grout Seal Type of Grout <br /> I f Irrigation —.Approx. Depth I 1 Eastern Ste Seal Installed by <br /> Repair Work Done tU_ Type of Pump H.P. State Work Dona <br /> Well Destruction ❑- Well.Diameter Sealing Material & Depth <br /> t Depth Piller Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> a v I available within 200 feet.I <br /> I Installation will serve: Residence'_ Commercial_ Other j <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 Capacity No. Compartments <br /> PKG. TREATMENT PLT: D.-'--' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size "} <br /> FILTER BED ❑ Distance to.nearest: Well Foundation Property Line ` <br /> SEEPAGE PITS j 11 Depth Size Number <br /> i 1 r <br /> SUMPS C3 Distance to' Weil Foundation Pro in <br /> t�►tY <br /> L e <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 p$rsons subject to workman's compensa- <br /> tion laws of California." 1 <br /> The ap ' t must II for all required ' ctio omplete drawing on r(�®rs�ede. <br /> i <br /> Signed X Title: �' ; Date: <br /> FOR DEPARTMENT USE ONLY ti <br /> Application Accepted by Date t– A ea <br /> Pit or Grout Inspection by Date Final Inspection by Data�� <br /> Additional Comments: <br /> 1 a ' <br /> Applicant - Return all copies' to: San Joaquin County Public Health Services <br /> Environmental Health ermit/Services <br /> 445 N San Joaquin, Box 2 9, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DTE PEAM17 N0. <br /> EH 11-20 !� <br />'e <br />