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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �O <br /> l ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BO% 2009,,I�STOCKTON, CA 95201 N <br /> (209) 468--3447TRES <br /> 1 R a - <br /> (Complete in Triplicate) <br /> Application is hereby trade to San Joaquin County for apermit to construct and/or install the work herein described. This <br /> a lication is mala in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> PP <br /> Joaquin County Public Health Services. I <br /> / 112b ©� 1– � City � Lot Sire/Acreage <br /> eC Job Address <br /> t IAddress rg t Phone 3� <br /> -� Owner's Name <br /> Glicense No. Phone <br /> ontsactor Address <br /> TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT C7 DESTRUCTION ❑ Out Monitoring Yell [of Service idell L'17, <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEINER LANES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ,A CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Die. of Weil Excavation <br /> Specifications- – <br /> U <br /> Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Type of Grout <br /> ❑ Public 1'1 Other ❑ Delta Depth of Grout Seal <br /> CJ Irrigation Approx, Depth ❑ Eastern Surface Sedl Installed by <br /> Repair Work Done 0 Type of Pump H.P. r. State Work Dona <br /> Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter ;, <br /> Depth Filler Material i Depth <br /> E ` TYPE OF SEPTIC WORK: NEW INSTALLATION T �,t TON (No septic system permitted if public sewer is <br /> is within 200 lest.l <br /> installation will serve: Residence— Commercial Other! <br /> Number of living units: Number of bedroo 4,arm y have ex hd <br /> Character of soil to a depth of 3 feet: Water table depth <br /> ait No. Compartments <br /> SEPTIC TANK ❑ Type/Mfgby <br /> PKG. TREATMENT PLT. ❑ 'iV11�O1t7�­.� 1 � D��;+�10� Method of Disposal <br /> Distance to nearest: Well Foundation operty Line <br /> .6 <br /> length/size <br /> lengt <br /> LEACHING LINE Cl No. 8 Length of lines h TotaW <br /> FILTER BED n Distance to nearest: Well 10 Foundation Property Line <br /> e <br /> SEEPAGE PITS 11 Depth Size Number <br /> n <br /> SUMPS L1 Distance to nearest: Well 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 laws, and <br /> rules and regulations of the San Josquin County 11 <br /> Home owner or licensed agent's signature certifies the following; "1;certify that in the performance of the work for which this permit is.issued, I shall not <br /> amploy any person.in such manner as to become.subject to workman's compensation laws of California," Contractor's hiring or subcontracting 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 compares <br /> tion laws of California." <br /> The applicant mu all for all required inspections. Complete drawing on reverse side. p / <br /> F Title: Date: 3 2 `Z– r/ <br /> f Signed – <br /> II <br /> F!G= <br /> Y y <br /> Application Accepted by Date ! Area <br /> .�.-- <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> IA <br /> I Additional Comments: <br /> Applicant R Return all copies to: SAN JOAQUIN COUNTY:;PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN,I:P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE MOUNT/DUE AMOUNT REMITTEDC K !�RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> ( 91—b <br /> EH 11241REV.+�A51 3D :r?� f 4. � !I <br /> {:H 7624 _ <br />