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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 /> application is made in coupliance frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job AddressL City d Lot SizeJAcreage <br /> J,- Owner's Name <br /> Address ~� Phone <br /> �Conlractor6- Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Weil ❑ <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 WELt PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications \\ <br /> I'1 Public Cl Qlher -_`�'� `fl'Delta- - --Depth of Grout-Seal- —-- - —Type-of Grouter �[ <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done L] Type of Pump H.P. State Work Done - <br /> Well Destruction O Wall Diameter Stalling Naterial i Depth <br /> Depth Filler Material i Depth <br /> r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I (No septic system permitted it public sewer is <br /> e available within 200 feet. <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of sod to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ .Type/Mfg Capacity s No. Compartments <br /> PKG. TREATMENT PLT,❑ I Method of Disposal <br /> Distance to nearest: ,Well_ _Foundation.- -- -P.ropeny Line <br /> ,LEACHING LINE ❑ No. A Length of lines ✓ Total length/size <br /> FILTER BED O u anto nearest: Well Foundation Property Line <br /> / <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well f Foundation Y Property Line <br /> DISPOS PONDS ❑ <br /> I hwd6y 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 oenifias 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 becoms.subj6ct to workman's compensation laws of California."Contractor's hiring or'sub•contracting signature <br /> candies 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 California2." <br /> The applicant cwt-rra for ad r uir Ctions. Complete drawing on reverse side. <br /> igrted Tide: ..-V -Jb,n.M4� r Date: - <br /> OR DEPARTMENT USE ONLY 1 <br /> Application Accepted by Date Area L� <br /> Pit of Grout Inspection by Date Final Inspection by Data <br /> Addi[br4lf Comments. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> i Environmental Health Permit/ServiceB <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201. <br /> FEE AMOUNT DUEAMOUNT REMITTED ECEIVED BY DATE PERMIT'NO. <br /> INFO6�52p� J 1'� <br /> CA5H <br /> • EIS 13-24 tREV.+I K SI 2- <br /> � A <br /> � <br /> EH 11-2a <br />