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• `APPIdCATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> p 0 BOX 2009, STOCKTON, CA 95201 <br /> PMIT EXPIRE 1. ,IE-AR FROM D TE SU <br /> (Complete in Triplicate) z <br /> Application is hereby made.to Ban Joaquin county-tor a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Healtyflervices. <br /> Ci Lot Size/Acreage <br /> Job Address <br /> i s ame <br /> Phone <br /> NAddress <br /> L ; <br /> C n d Se N04auo=Pho <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR 0 � �. �� ,�- OTHER ❑ <br /> Monitoring Well ❑ <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 CONSTRUCTION SPECIFICATIONS �. I <br /> C7 dustriel ❑ Open Bottom ❑_Manteca Dia. of Welk Excavation Oia:of:Walt Casing <br /> mesticlPrivate ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications L <br /> 1 Public - Other �""" °171-Delta' Depth of Grout Seal Type of Grout <br /> I I Irrigation <br /> Approx. D I4Elenrurfsce Seal Installed by <br /> Repair Work Done L7 Type of PumpCA <br /> H.P. _^ __ Stats Work Dons <br /> Sealing tfaterial A Depth <br /> Well Destruction O Well Diameter -f r i <br /> Depth Filler Hateriji i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will some: Residence...r Commercial^ Other <br /> f Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: Water table depth \ <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. CompartrimAW <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> —Distance-to.nearest:,e-....Well T:-_--_., ,.Foundation- :Property_Une.,-- <br /> LEACHfNG LINE ❑ No. 6 length of lines <br /> Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I s Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line ` <br /> DISPOSAL PONDS a <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 /> rubs and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: 111 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 subcontracting signature <br /> certifies the following: '11 car"tifithat in the performance of the work for which.this permit is issued, I shall empioy persons subject to workman's e compensa- <br /> tion larva Of Itorltia. <br /> Tt <br /> The app) t st cal{ fired spactions. Complete drawing o ver sed / <br /> Signed • A A 0 Ti Date. <br /> FOR DEPARTMENT USE ONL <br /> Application Accepted by C Date Area <br /> Pit or Grout inspection by Date Final Inspection by Date 7 /L <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Spvironmental Health Permit/Services <br /> 445 N San Joaqula, ox 2009, Stkn, CA 95201 <br /> INFO (�AMOUNT DUE A UNT REMITTED CASH ECEIVf BY D TE PERMIT N0. <br /> . EH*24IAEH.I/a51 <br /> EM 1416 r <br />