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APPLICATION FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> 3 .PERMIT EXPIRES •I YEAR PROb. DATI's ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address mry 2Lot Site/Acreage <br /> Ow er's Nama Address• ` r Q• ✓'-�Q l Phonee�Y, — ' <br /> r <br /> C nt actor Addres <br /> � - License N0, e� Phone _2f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O 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 <br /> 0 industrial . ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> mastic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ill Other ❑ Delta Depth of Grout Seal Type of Grout <br /> MI Irrigation —.Approx. Depth ❑ E tern �rface Saul Insialied by � <br /> Repair Work Done L7. Type of Pump H.P. s State Work Done._ <br /> Well Destruction O Well Diameter 4 It Sealing Material i Depth <br /> A Depth _74-1_ Filler Material k Depth Wi TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewavailable within 200 leet.l <br /> Installation will serve: Reiidenci`: Commercial Other f� <br /> Number of living unity: Number of bedrooms: lJ <br /> Character of axil to a depth of 3 feet: .- . . 3 1. <br /> Water table depth <br /> SEPTIC TANK. ' ,p - Type/Mfg F = Capacity No. Compartments <br /> PKG. TREATMENT PLT,: C] Method of Disposal <br /> r Distance to nea\rtl-,_ <br /> We11 Foundation Property Line <br /> t <br /> LEACHING LINE CI No..B-Length of lines . Total length/size ' <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth"' `^ -' Site 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 laws, ander <br /> rules and regulations of the San Joaquin County ' <br /> Moms owner orlicensed`agenYiaignature Cenifias`tTse foliovvirig:"I certify that in the performance 0 the work for which-this permit isissued I shall not <br /> employ any person in such manner as to become subject to workman's compensation+laws of Ciblornia.'%'Contractor's hiring or sub-contracting signature <br /> certifies the following: "I canify that in the performance of the work for which this permit ii issued,t,shali enriploy persons subject to workman's compensa- <br /> tion laws of California." <br /> t <br /> The applic us4 tailI r all iced inspections. Complete drawing on raver ide; <br /> Sip d tt Title: <br /> Date: <br /> OR D ARTMENT USE ONLY <br /> Application Accepted by Date ��- <br /> Area <br /> Pit or Grout Inspection byDate Final Inspection by Dots f <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN'COUNTY PUBLIC HEALTH SERVICES T <br /> ENVIRONMENTALIHEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN/JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> 4 <br /> FEE AMOUNT Ot1E AMOUNT REMITTED CKINFO CASH <br /> AECEIVED BY DATE PERMIT NO. <br /> - <br /> + EH 13.24(REV.oHsi �`^Q 4 !` <br /> EH;x•10 •�v?'—L —4.��V <br />