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-0+ -� �.-.,.� '^+•+mss <br /> APPLICATION FOR PERMIT *� <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 I 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 /> I application in made-in-i:otspliance with San Joaquin--County Ordinance No. 549 and 1$62 and the Rules and Re <br /> Joaquin Co -PR_blic Health Services. / guLtioas of San <br /> ur y <br /> Jab Address �� f Cit Lot Size/Acreage <br /> Owner's.Name ` Address Phone ✓ a <br /> Contractor - - <br /> dress License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL [2 WELL REPLACEME F7 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ClMonitoring Well n <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 CONS1RA CTIOILSPECIFIC_ATIONS t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications C <br /> 11 Public Cl Other n Delta Depth of Grout Seal # Type of Grout <br /> I i Irrigation ____Approx. Depth I I Eastern Surface Seal Installed by i <br /> r <br /> Repair Work Done U Type of Pump H.P. `State Work Dona.._ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Naterial Depth <br /> TYPE OF SEPTIC WORK:X NEW INSTALLATION I I REPAIR/ADDITION tl DESTRUCTION I I (No�seplic system permitted if public 4,2 - <br /> SEPTIC <br /> ; <br /> available within 200 feet.! <br /> Installation will serve: Residence_ Commercial—! Other <br /> Number of living units: J_ Number of bedrooms i <br /> Character Of 600 to a depth of 3 feet: - _ - Water table depth <br /> TANK ❑ T _ I <br /> ype/Mfg Capacity Na. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> _._. 1 <br /> Distance to nearest: Well Foundation Property Luis <br /> LEACHING LINE ❑ No. 6 Length of linea 9t+ <br /> Tdtal length/size <br /> FILTER BED ❑ Distance to nearest. Well Founds ion Property Line s <br /> SEEPAGE PITS I I Depth Size N� Number <br /> SUMPS C1 Distance to nearest; Well 40 M <br /> Foundation Property Line ; <br /> DISPOSAL PONDS ❑ <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 law:, 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 shell not <br /> emptoY 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 perfofmarice of the work for which this permit is issued,1�hall employ persons subject to workman's compensa r <br /> tion laws oft <br /> " , <br /> The applica1 ns io Complat ng on reverse side. x 4 <br /> s <br /> Signed ` Title: <br /> Date: <br /> O DEPARTMENT USE ONLY <br /> Application Accepted by Date ?_ Area ® � Q% <br /> Pk or Grout Inspection by Date Final Inspection byr" <br /> Additional Comments: Date <br /> Applicant - Return all copies to: San Joaquin County Public Health Services t�t� <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> fEE AMOUNT DUE AMOUNT REMITTED CK <br /> INfO CASH RECEIVED BY DATE AERMIT•NO. <br /> i <br /> • EH 13-20 t11EV,I/r 5 <br />