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APPLICATION <br /> SAN a,jAQUIN COUNTY PUBLIC HEALTH` .,RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -$ <br /> I (Complete ' in Triplicate) ! <br /> u <br /> 1 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 /> i <br /> Job Addressl �. � - City Lot Size/Acreage '" <br /> Owner's Name Address 0 Phone <br /> •;1 <br /> I: [ <br /> II 'Contractor ess cense No� Phone <br /> �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM NT 17.1DESTRUCTION Out of Service.well ❑ <br /> `` PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER D Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> Er i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom I-] Manteca Dia. of Wel! Excavation Dia, of Well Casing <br /> ❑ Domestic/Private 0 Gravel Pack ❑ Tracy' Type of Casing Specifications <br /> I'1 Public Cl Other `1 Delia Depth of Grout Seal Type of Grout <br /> i 1 1 Irrigation —Approx, Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done L] Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter "Sealing MdterlsY i Depth <br /> 1 Depth Filler Material-i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTOUCTION I 1 INa septic system permitted if public sewer is <br /> r E; available within 200 feet.1 <br /> Installation will serve: Residence Commercial T Other <br /> Number of living units: Number ofoms <br /> 1 !Character of loll to a depth of 3 feel w Water Table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> " PKG, TREATMENT PLT. ❑ y1 Method of isl <br /> li <br /> DiC.J <br /> stance 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 10— <br /> �I <br /> y <br /> I Depth Number SEEPAGE PITS Dep Size ti <br /> �i. SUMPS 11 Distance to nearest: Well ; Foundation'— Property Line <br /> DISPOSAL PONDS ❑ f <br /> 1. I hereby certify that 1 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 periormance of the work for which this permit is issued, I shall not I <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 /> jcertifies 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." 4 <br /> The applicant u t r uir d s tions. Co I rowing on r arse side. <br /> Signed Title: Date: . <br /> i F R DEPARTMENT USE ONLY <br /> Lk <br /> 14 ! Application Accepted by Date �- r 4l _ Area <br /> I 4 [ I <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> AdditionalComments: <br /> ki <br /> 1! Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Eavironmental .Health Permit/Services <br /> 445 N San Joaquin, P O Sox 2009, Stkn, CA.95201 <br /> I. <br /> CK J <br /> ii <br /> INFO ~` AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. <br /> II � i <br /> EH t3-24tR£V.liwsl C,/7 !per �d� 1 �� -© <br /> EH 14.2a �`"'- <br />