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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 'A +Co <br /> ENVIRONMENTAL HEALTH" DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-34 20 /x 1 (�.(� i <br /> P O BOX 2009, STOCKTON, CA 95201 �U <br /> PERMIT EXPIR S I YEAR FROM D TE SUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Baa Joaquin County for a permit to construct and/or install the work herein described. This <br /> l application is made in ccupliance with San Joaquin County ordinance No. 5h9 and 1862 and the Rules and Regulations of San" <br /> Joaquin County Public Health services. <br /> City Lot Size/Acreage <br /> I Job Address <br /> hone <br /> Owner's Name <br /> ',Address 3'� +Q <br /> r• r.�' � l <br /> 4 Contrac <br /> Address - -�-�tifcense N L'3� Phone <br /> TYPE OF WELL/PUMP:, NEW WELL C3WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> " Monitoring Well <br /> "PUMP INSTALLATION LI SYSTEM REPAIR Cl OTHER ❑ <br /> DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLP. PROP. LINE <br /> FOUNDATIONi AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE"- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing !tel <br /> L7 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation <br /> T of Casing_ Specifications <br /> amestic/Private ❑ Gravel Pack L7 Tracy Type Type of Grout <br /> I'l Public 171 Other " 1­1 Delta Depth of Grout Sea] <br /> I ! Irrigation Approx..Depth I I Eastern Surface Saul Installed by <br /> f Repair Work Donee."L] Type of PumH.P. $'�� State Work Done <br /> Pump _ <br /> [ Sealing Material i Depth - <br /> !4 Well Destruction ❑ Well Diameter Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I Ravailable E Ir,DESTRUCTION I I septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence____ Commercial— Other "'s ",';""1•v <br /> Number of living units: Number of bedrooms '" <br /> Character of soil to a depth of 3 feet: Water table depth! <br /> No. Compartments <br /> SEPTIC TANK O Type/Mfg - � Capacity----___:. <br /> PKG. TREATMENT PLT..❑ Method of Disposal <br /> Distance to nearest:, Well FoundWon Property Line <br /> .t <br /> { ^LEACHING LINE �b No. 5 Length of lines Total length/size <br /> t FILTER BED C1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size <br /> SUMPS L1.. Distance to nissrest: 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 a4 cordance with San Joaquin county ordinances, state laws, and <br /> rubs 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 compensatipri`Is'ws of California." Contractor's hiring or sub-contracting signature <br /> t 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 compansa- <br /> tion laws of California." <br /> The applican wired In do Complete drawing on verse side. <br /> Signed Title: Date: -- <br /> Y <br /> FOR DEPARTMENT USE ONLY 7 Aro �/� <br /> Application Accepted by Date D <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> ' Applicant - Return all copies to: San Joaquin County_,Public Health Services <br /> r Eavironmentil4liealth Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> . . . <br /> FEEAMOUNT D E AMOUNT REMITTED CKffl H RECEIVED 9Y GATE PERMIT"NO. <br /> ✓ INFO <br /> . t +u-xrnEv."vest <br /> Err,..10 <br />