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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ' a <br /> P O BOX 2009, STOCKTON, CA 95201MAY <br /> (209) 468-3447 <br /> ENVIRONMENTAL <br /> PERMIT EXPIRES 1 YEAR PROM DATE ISSUED PFRMI+T/S ?�rj(��t��;j� <br /> EA <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or instal]. the vork herein described. This <br /> application is made in compliance vtth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, �-` <br /> Job Address 's so,6"_ 44"d,�"a'�d City._�C Lot Size/Acreage <br /> Owner's Name <br /> Address -� (__ Phone <br /> Contracto Address�d lla +�a- 3 License No. _2- Phone _,Lw/sc <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 3}--� OTHER ❑ Monitoring Well a <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 /> 1.1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> P160-mestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> A Public f 1 Other ' ,0 Delta, Depth of Grout Seat Type of Grout <br /> Cl lrfi0ation Approx. Depth ❑ Eastern urface Seal Installed b;, <br /> ' <br /> Repair Work Done Type of Pump dJdd:c = H.P. L2— State Warks Done" <br /> Well Destruction ❑ We'll Diameter Sealing Material i Depth --' <br /> Depth Filler Material i Depth ' <br /> TYPE OF SEPT,IC WORI(; NEW INSTALLATION❑ REPAIR/ADDITION 1<i 'DESTRUCTION Cl <br /> .(No septic system permitted if public sewer is- <br /> �- _'-..'- "c` "`_'^ '� - ._ _n - •• - .;.#.r- available within 200 feet.) <br /> Installation will serve: Residence_) Comrrterciat Other <br /> Number of living units: Number Ofbedrooms ` <br /> Character of soil to a depth of 3 feet: µ Water table depth <br /> SEPTIC TANK. ❑ T ype/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 1711 Distance to nearest: Well Foundation Property Line <br /> r <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS LI 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 laws4and <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 sha . <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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 applicant mu all for all r inspections, Complete drawing on verse side. <br /> SignedDate: <br /> Title: _ - <br /> .,,...__..., <br /> R DEPARTMENT USE ONLY /t <br /> Application Accepted by Date 4 Area �`r <br /> Pit or Grout Inspection by Date Final Inspection by Date 6 �/ <br /> Additional Comments. <br /> Applicant - Re tura 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 95201 <br /> FEE INFO - AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> + EH 13.24 I11EV.1/n s! <br />