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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 /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EUIRES I YEAR FRQ1L 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 ce®pl1&nce with San Joaquin County Ordinance No. 51+9 and 1662 and the Rules and Regu <br /> Joaquin County Public Health Services. lations of San <br /> <{''� ) <br /> X Job Address SJ�.3 CJ« J> S CAl � f!^4 C' <br /> City �� Lot 51ze/Acreage / <br /> Owner's Name <br /> Address .� t2cS��'ist ( -/ �5'.�.. �^• <br /> �[ � .. PF1one 7 <br /> / Conlraclor �c�jr ./J Address <br /> License No. Phone <br /> TYPE OF WELL/PU P:. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ put of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANKC7 <br /> 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 ❑ Manteca Dra..of Well Excavation <br /> f' Dia. of Well Casing <br /> I') Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> I'1 Public, 1-1 OtherSpecifications <br /> 171 Datta Depth of Grout seat Irrigation I I Type of Grout <br /> —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done Y / <br /> Well Destruction ❑ Wel! Diameter Sealing Material L Depth IV1� <br /> Depth Filler Material i Depth r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is <br /> V 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: t \1 <br /> SEPTIC TANK ❑ T Water table depth ✓7�_7 <br /> Type/Mfg l Capacity <br /> PKG. TREATMENT PLT,❑ No. Compartments <br /> .,.Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines. -- C) <br /> FILTER BED Total length/site <br /> [`] Distance to nearest: Well_- erO r Foundation <br /> Property Line <br /> SEEPAGE PITS f I Depth Size <br /> Number <br /> SUMPS L! Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Lina <br /> 1 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 V J <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, t 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 workman's compensa- <br /> tion laws of California.' <br /> The applic nt must call for al uired inspections. Complete drawing on reverse side. <br /> xSigned pate: <br /> Title: —y-:ZT�[ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by DateA ` <br /> rea ��b <br /> Pit or Grout Inspection y Date <br /> — Final Inspection by Data +� <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 0 Box 2009, Stkn, CA 95201 <br /> FEE AMO NT DUE Aj11T REMITTED INFOCV)10 BY 0 E PERMIT'NO. <br />. EH 13-2�IREY.t�MSI <br /> EH 1476 <br />