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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 O BOX 2009,, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ��/� /' City Lot Size/Acreage <br /> Owner's Name !° 'r "^��„� lrlttl.Ci/1 Address e� Phone <br /> Contractor Address ggQaAIV License No.'s Phone f �� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION t of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 <br /> jDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> --El Industrial. - Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> .1 Domestic/Private ❑ Gravel Pack El Tracy Type of Casing_ Specifications <br /> I'I Public [.1 Other n Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation —..Approxi Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump H,�.P State Work Done J z <br /> Well Destruction , Well Diameter ilio” sling Material S Depth q��Ph1 1?1<� "!!!tV G(lf 4�j <br /> pth I Filler Material 8 Depth C d �� Z RaG 46P-AiEaj SA15 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 PAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if priblic sewer is <br /> available within 200 teat.) <br />` Installation will serve: Residence___`_� Commercial_- Other <br /> a <br /> Number of living units: Number of bedrooms <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. ❑ I. Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ' <br /> k =. LEACHING LINE ❑ No. & Length of lines Total length/size f a <br /> x ! FILTER BED 0 Distance to nearest: Well Foundation Property Line t <br />` SEEPAGE PITS_ 11 Depth f Size Number _.r <br /> f� ,? <br /> SUMPS LI Distance io nearest: Well Foundation Property Line <br /> DISPOSAL-PONDS ❑ 1: <br /> I 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 j <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 /> F 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 compen' <br /> tion laws of California." k. <br /> The applican7 1. all req ons. Complete drawing on reverse $we. <br /> t <br /> Signed X Tide: Date: f <br /> 'u OR DEPARTMENT USE ONL t a <br /> Application Accepted by{ DateL Area <br /> Pit or Grout Inspection by Date Final Inspection by �� Date <br /> Additional Comments `Ak l ► - <br /> t <br /> Applicant - Return all copies to:, San Joaquin County Public Health Services <br /> - rf Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEEi <br /> CK <br /> INFO AMOUNT DUE AMOUNT REMITTED :C SH '! LSREGEIVEp BY DATE PERMFT'NO. <br /> �a EH1EY.IiNs1 � 6,8, 0 <br /> EH t4.26�.7a - 'F <br /> d <br />