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SAN JOAQUIN COUNTY PLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> a 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> n f-- P O BOX 2009, STOCSTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> (Complete in Triplicate) <br /> I <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This I <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 /> � r � r <br /> Job Address� r/ City ov at BLo~ ze/Acreage <br /> C <br /> Owner's Name; P - Address w Phone <br /> Contractor <br /> Address � icense NS5 C Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 0 • - SYSTEM REPAIR'S OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION *AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> [Domestic/Private ❑ Gravel Pack* ❑ Tracy Type of Casing_ Specifications <br /> I•I Public C1 Other n Delta r Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation 1 _..Approx. De th /-�1_11 Eastern Sine Seal Installed by <br /> Repair Work Done 11Z Type Type of PumpH.P. -1 15 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Depth <br /> Depth Filler Material Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <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 j <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 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 sws worZans' mpensa <br /> tion Iof Cafiforn ' <br /> i <br /> The al ust ca for all required ins coons omple drawing on re er side. <br /> Signed Title: Date: <br /> n F��141EIVT USE ONLY <br /> Application Accepted by �/I�i J,��. \1��•aar= --- Date ` A a �- <br /> Pit or Grout Inspection by Date Final Inspection by Date <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, 11 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK AECEIVE BY pAT PERMIT'N0. <br /> INFO �n <br /> . 10 <br /> EM 43.24 IREV.i I x 9 (Jv �� <br /> EN 14•2a <br />