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+sr �A ' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 ule <br /> Y R(Complete in Triplicate) pEApplication is hereby iaadeto San Joaquin County for a permit to construct and/or install. guai <br /> ed. This <br /> application is made in coupliance with San Joaquin County. Ordinance No. 549 and 16 and ta of San <br /> Joaquin County Public Health Services. <br /> Job Address City Size/Acreage <br /> Owner's Name las <br /> • 4 Phone <br /> Cantracio Address r icense IN Phone <br /> TYPE,O.F WELL/PUMP: NEW WELL q WELL REPLACEMENT _ DESTRUCTION ❑ Out of Service Well ❑ <br /> � - PUMP INSTAL TIO SYSTEM REPAIR ❑ OTHER p Monitoring tiiell C7 <br /> DISTANCE TO NEAREST�-SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS <br /> _ <br />— - — . . -- <br /> INTEIVpfp USE " TYPE OF WELL— MPROBLE-Ai1 AREA CONSTRUs.-CTI-'1ON- SPECIFICAI`IONS"" <br /> n�Ind'atrial p Open Bottom 0 Manteca Dia. of Well Ekcavation Dia. of Well Casing <br /> estic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications <br /> rig <br /> 7/R Public I'1 Other ❑ Delta Depth of Grout Seat Type of Grout F <br /> Cl IrriUauon —.Approx, De h Ea tern Surface Soul Installed by <br /> Repair Work Done v Type of Pu H.P. 7:0 -State Work Done _ <br /> Well Destruction © Well Diameter Sealing Material is Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-0—REPAIR/ADDITION 71 DESTRUCTION 0 (No septic system permitted if public sewer is t <br /> available within 200 feet.) <br /> Installation will serve: Residence Comrrieicial Other <br /> Number of living units: Number of bedrooms' <br /> Character of axil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg �' Capacity No. Compartments m <br /> PKG. TREATMENT PLT. Ci '�,f Method of Disposal <br /> Distance to nearest: Well Foundation t Property Line' <br /> LEACHING LINE L1 No. & Length of lines r= W Total length/sire <br /> FILTER BEDf I Distance to nearest: Well Foundation I Property Lina; <br /> l• 4 <br /> SEEPAGE PITS 11 Depth Sire <br /> Number <br /> SUMPS Ll Distance to nearest: WallFoundation Property Line <br /> DISPOSAL PONDS .. p F I <br /> I hersby feedify that I Neve prgpered'this bWpTcation ah?thaf the wbrlt vviil be done 7n accdrdance wiih San'Joaquin couriiy 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 /> employany person ih succi irtanner as tto become subject to workman s compensation laws of Cal'rtpmia." 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 shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant st call or squired inspections, Complete drawing an re Me side. <br /> Sign Title: Date: <br /> F DEPARTAAENT USE ONL 9 �f <br /> Application Accepted by Date ��� � ~Y� Arra <br /> Pit or Grout Inspection by Date Final Inspection by.. __ . Date D <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 <br /> FEE: AMOUNT 0t1EAMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT NO. <br /> - <br /> el+13•24[REV. ?O T � <br />