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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 1 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 cott�iliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> &_bA� <br /> Job Address Ci t Size/Acreage <br /> i <br /> ff r w ra Name <br /> Address Phone&_ 7 <br /> t <br /> Un Pc }y ' <br /> d 1� L ce se No, hone <br /> TYPE OF WELL/PUMP: �I NEW WELL WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATI SYSTEM REPAIR ❑ OTHER LJ Monitoring Well CZ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOLIpODATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> mstic/ <br /> stnal ❑ OpenBottom C1Manteca Dia. of Weil Excavation iDia. of Well Casing <br /> Private ❑ Grevel'Pack ❑ Tracy Type of Casing_ Specifications <br /> F) Public. 1.1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. D�lh t I Eastern _ Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Workrpone <br /> Sealing Material & Depth ^` <br /> Wall Destruction O Well Di ter _,,, r �t" � � � � ,•\ <br /> Depth!, <br /> t Filler Material i Depth KAI <br /> -a. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 Moseptic system permitted if public sews s <br /> �`i available within 200 feet.) ... <br /> Installation will nerve: Residenlce Commercial Other <br /> I ��- Numbeof living units: Number f badrooms <br /> Character of soil to a depth of,`3 feat: / �" Water table depth <br /> SEPTIC TANK. O .Typi/Mfg Capacity No Compartments <br /> PKG. TREATMENT PLT.D �� I '� - Method of Disposal N <br /> Distance to nearest: Well Foundation Property Line O <br /> i <br /> LEACHING LINE 'b No�3 Length of lines w Totals length/size,, . t <br /> FILTER BED 0 ,Distance ea <br /> tance to nearest: Well Foundation V ' Property Line )�, <br /> ) <br /> I� f <br /> SEEPAGE PITS It Depth Size Number 1 <br /> .SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS - ❑ I� <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San'Joaquin county ordinances, state laws, anxib�__ <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 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."C6ntrectors 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 shall ernptoy persons subject to workman's compensa- <br /> tion laws Nornio." A <br /> The appl ust call ved i pactions. Com lets drawing on arse sid y�~. <br /> qA <br /> S' Title: Date: <br /> j1i 01J FOR DEPARTMENT USE ONLY _T w <br /> Application Accepted by Date 1 A.. I <br /> Pit or Grout Inspection by IF T Date Final Inspection by Y D_. <br /> }Additional Comments: ' <br /> P. -Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 1 „ 445 N San.Joaquin, P O Box 2009, Stkn, CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED K REC LVED BY 0yiE PERMIT-NO. <br /> �� <br /> . EH 13.24 IREV. r e b) P 6D f 3 D <br /> EH 14.26 i <br />