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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 f <br /> P 0 BOX 2009, ` STOCKTON, CA 95201 <br /> t <br /> PERMIT EXPIRES I 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 vith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ,�w Q <br /> �J V City Lot Size/Acreage r 0/ c? 0 ` <br /> Job Address l <br /> g± <br /> Owner's Name�,.�__ _ q iJf`�- Address Phone <br /> L 1 ./' <br /> Contractor��`-L� ---Ad'd'ress L 0 MLicense No. +- Phone - <br /> TYP_E_OF WELL/_P_U.MP_: , ,.NEW WELL C7 WELL REPLACEMENT ❑ DESTRUCTION o Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 177 OTHER ❑ Honitorfng Well« <br /> DISTANCE TO NEAREST: SEPTIC TANK: SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> — --- ._ell.... Eixcava__tion `"r- bia:of`V11e'll'Casing <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia,--R- <br /> of WE <br /> f7 Domestic/Private C1 Gravel Pack7­ ❑ Tracy Type of Casing_ Specifications <br /> 11 Public C1 Other 171Delta Depth of Grout Seal Type of Grout ; <br /> 11 Irrigation Approx. Depth 11 Eastern Surface Seal Installed by ) t <br /> Repair Work Done U Type of Pump H.P. --- State Work Done <br /> Weil Destruction ❑ Well Diameter Sealing Material JG Depth } <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW-INSTAL-IATION-1-1.-REPAIR-/ADD ITION STRUCTION I I (No septic system permitted it public sewer is <br /> f available within 200 feet.) <br /> Installation will serve: Re 'dente Z�ommercial— Other t <br /> Number of living units: Number of bedro ms <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. ❑ 1 # r Method of Disposal <br /> Distance to nearest: e11 i Foundation J 0__ Property Line-Qis;lf <br /> At F <br /> LEACHING LINE & Length of lines Total length/size <br /> FILTER BED ❑ }Distance to nearest: Well Foundation Property Line <br /> it 4 i <br /> WPM- <br /> SEEPAGE PITS I I Depth _�_ Size ? Number { <br /> SUMPS &—trito 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 inaccordance with'San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County 1. .' i <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 f <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 la f California." <br /> The applicant t ca fo all r uire t spec' a. Co ete drawing on r rse side. , <br /> Signe ide: Date: <br /> OEPARTMENT USE ONLY x <br /> Application Accepted by Date �~ / Area / <br /> 47 <br /> Pit or Grout inspection by. Date .Final Inspection by S5 - Data /S� 3 <br /> Additional Comments: <br /> t, <br /> + Applicant - Return all co ies to: San JoaquiniCounty Public Health Services <br /> "'Etivironmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOU REMITT CK E EIVED BY DA PfRMiT N0. <br /> INFFO <br /> EH t]-2�(REV. /KSS�Y <br /> V__ �l - <br /> Eri 11-2e I� iii <br />