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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 /> ssG / 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 /> applcation 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. I <br /> JobAddress City C_ Y�� Lhot Size/Acreage <br /> 5dL y. b in 2 p � O <br /> Owner's Name Address <br /> C <br /> Phone <br /> Contractor C M Address 3O.S1 Alvl- License No. Phone Y6',;2 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well. ❑ <br /> PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER �So. jMgpi�to'ring Well C]DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation l Dia. of Well Casing <br /> n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public fl Other n Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation ZfApprox. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter sealing Material i Depth <br /> Depth / r� Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 2W 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. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/sue <br /> FILTER BED ❑ Distance to nearest: Well Founaation Property Una <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS Ll Distance to nearest: WON Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 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 persona subject to workman's compensa- <br /> tion laws of A-'ornla.' <br /> The applies [ 4 11 required inspections. Complete drawing on reverse side. <br /> Signed f . Title: <br /> Date: <br /> v <br /> FOR DEPARTMI&T USE WNLY <br /> Application Accepted by Date <br /> Area <br /> Pk or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County P-.lic Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO CASH DATE PERMIT NO. D��� 13C <br /> 1 13-24(REV.l i n S) I L <br /> J i4 20 <br />