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APPLICATION 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 .ESPIRES 1 YEAR P999 .12ATE <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the uii �� d;19 ibed: This <br /> application is made in co*liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules gulls Jons',,br'6an <br /> Joaquin County blic alth Service2 Uh <br /> . j , /, �r <br /> Job Address`r"6 7 <br /> J Cit o Size/Acreage(��C <br /> Owner's Name Address Phone r <br /> Cntra r gess' Li nse N0. f7 Phone��� <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION SYSTEM REPAI OTHER ❑ 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 /> \\n�Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> Domestic/Priv-ate - C1 Giavef Pack' `- —❑ Tracy' Type of Casing Specifications <br /> M PPublic I-1 Other 0.Delui` Depth of Grout Seal Type of Grout <br /> Gi Irrigation _ .Approx. DepthEastern ' dace Seal Installed by 1 <br /> Repair Work Done 0 Type of Pum H.P. Ste ork one_ ' <br /> Well Destruction ❑ Well Diameter - Sealing Material i Dcpth <br /> Depth ri Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION C1 INo septic system permitted if public sewer is <br /> ' available within 200 feet.f <br /> J ' <br /> Installation will serve: Residence Commercial Other f" <br /> Number of living units: Number of bedrooms <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. a ' ` Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. 8 Length of lines Total length/size <br /> FILTER BED n 'Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation. Property Line - - <br /> DlSPOSAL PONDS ❑ -- - a <br /> 'I <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 anti-reg�ilaiions-of-the'San-Joaquin County R <br /> Home owner or licensed agent's signature eenifies 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 compensa- <br /> tion laws of California." <br /> The applicat cal for r fired inspections. Complete drawing on rev se side. <br /> Si ed Tide: Date: / �f <br /> F EPARTMENT USE ONL } ` � <br /> Application Accepted byu�/ Date _= ] Area <br /> Pit or Grout Inspection by Date Final Inspection by ' Date <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 0 BOX 2009, STOCKTON, CA 85201 <br /> - I <br /> INFO AMOUNT DUE �AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. <br /> . EH 1374(REV. Si dD f J, �. A 'f 1.1 Y ••--��' t� <br />