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APPLICATION <br /> :SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I f 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX .2009,' STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 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 with Ban Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address K - x 1 _ r <br /> - _ City Lot Size/Acreage �f7(9 X 7 <br /> r iS <br /> k � r- <br /> Owner's Name r� iV rt# IN� ddress �4 �� Pho e�3 <br /> Contractor � � # Address Licen's'e No. Phone <br /> l -TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER'LUNES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C) Industrial 0 Open Bottom ❑ Manteca Dia. of Well ExcavationOia. of Well Casing <br /> Ell Domestic/Private ❑ Gravel Pick El Tracy Type of Casing Specifications � <br /> I'I Public (-I Other 11 Delta Depth of Grout Seal <br /> Type of Grout <br /> I I Irrigation Approxi Depth ( I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth I Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms i <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ ' Type/Mfg <br /> p 5 <br /> PKC. TREATMENT PLT. ❑ �`—� No. Compartments <br /> Method of Disposal <br /> Distance to nearestPerrWiil�� ogda�inn� Property Line <br /> LEACHING LINE Cl No, & Length of 1 ae� com ate r_Or 10SPWOW4,ingthisize <br /> FILTER BED ❑ Distance to nearest y F"jr 4a of n Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well FoundationPro <br /> DISPOSAL PONDS ❑ Property Line <br /> I hereby certify that I have prepared this,application and that the work will be done in-accordance with San Joaquin county ordinances, stat <br /> rules and regulations of the San Joaquiri�County e laws, and <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 r <br /> employ any person in such manner as to become subject to workman's compensation taws 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." r <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> OR EPARTMENT USE ONLY <br /> Application Accepted by Date 1 Area <br /> Pit or Grout Inspect'ion by Date Final Inspection by <br /> Date <br /> Additional Commsnt D <br /> Applicant - Return lI copies to: San Joaquin County- Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> o FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO ( CASH RECEIVED BY DATE PERMIT'NO. <br /> EM+ EH 13.24(REV.f)x 5) "'% � 4't�� <br /> t_ %7-3iT pl-�D <br />