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APPLICAT!ION' FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR rROM 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> C t <br /> Job Address City4c Z, Lot Size/Acreage <br /> Owner's Name �@ ` Address /1sS_CAC Phone <br /> 4 Contractor Address,g��` f - lrf!'leLicense No �Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION O SYSTEM REPAIR 1X OTHER O Monitoring well C7 <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 ^' <br /> C� Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications <br /> M Public I 1 Other O Delta Depth of Grout Seal Type of Grout <br /> Ml Irrigation —Approx, Depth Eastern Surface Seal Installed by <br /> Repair Work Done epi[ Type of Pump H.P. -1 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Aaterial & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other In <br /> Number of living units: Number of bedrooms U <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. Q Method of Disposal <br /> Distance to nearest: Well Foundation Property Line 0 <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED C.1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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, and <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." 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 shall employ persons subject to workman's compo $211- <br /> ton laws of C ' <br /> T rcant must I for all required ' s ctions omplete drawing on r e side. <br /> Signed Title: Date:ell- <br /> _� <br /> FOR EP NT USE ONLY <br /> Application Accepted by —c) <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date Z <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 2009, STOCKTON, CA 95201 <br /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMII NO. <br /> EH A-A INEV.1/"5) ], Goh� I t-CA19 P <br />