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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH -oERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> . PERMIT E%PIRES 1 YEAR FROM DATE ISSUID <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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 7 <br /> T t r <br /> Job Address CityV�'LLl 1 Size/Acreage <br /> Owner's Nameale< �! ., Address N` Phone <br /> Contractor L Address � License No. KU PhoneZ 7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR )( OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications <br /> I'1 Public El Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth I/4 Eastern Surface Seal Installed by <br /> Repair Work Done fy Type of Pump ,6� •-(f--' FI.P. , State Work Done c <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (No 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 <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Propeny Line <br /> SEEPAGE PITS 11 Depth Size_ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 <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 workman's compensa- <br /> tion laws of C . <br /> The ap nt must ca for all required ins tions. Complete drawing on rev er si e. <br /> Signed X Title: �C Date: <br /> F RD PARTMENT USE ONLY <br /> Application b Accepted <br /> P Y Date �-_L Are <br /> Pit or Grout Inspection by Date Final Inspection b��,i�� Dat*!a /fes <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Healih Permit/Services <br /> 445 N San Joaquin, Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMO NT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CAS. f �! <br /> EH 13.24(REV.rrnsiPIP iq <br />