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- APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> E+IVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 2 P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EMI,RES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made t0 $eit Joaquin County form permit to construct and/or install the work herein described. This <br /> application is made in compliance with Ban Joaquin county Ordinance No. 549 and 1862 and the Rules and Regulations of Elan <br /> Joaquin County Public�,He"`alth services. <br />` Job Address / of Lot Size/Acreage <br /> 0 <br /> Owner's Name l Address L J t <br /> _Phonea3r__�/*,J4 <br /> ContratttN / 144ddress <br /> License No. 9Z Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT5< DESTRUCTIO t of Service Well L, <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK � � SEWER LINES /�f} DISPOSAL FLD. .PROP. LINE <br /> FOUNDATION AGRICULTURE WELL - r OTHER WELL-(allL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION f <br /> C1 industrial •� � <br /> D Open Bottom (�Manteca Die. of Well Excavatio Dia. of Well Casing <br /> t9pomestic/Private *4rsvel Pack L7 Tracy Type of Casing_ G Specifications <br /> Cl Public Cl Other f1 Delta Depth of Grout Seal Ty of Grou <br /> + I Irrigation / Appros. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H,P. Stats Work Dons <br /> Well Destruction ,� Well Diameter sealing Material i Depth i <br /> Depth filler Material i Depth <br /> TYPE OF SEPTIC:WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I + INo septic system permitted if public sewer is <br /> r <br /> h available within 200 feet.) <br /> ";—Installation will serve: ftesidenctt� CommercialOfher - <br /> Number of living units. Number of bedrooms <br /> Character of soft to a depth of 3 feet: [�1 <br /> SEPTIC TANK. Water table depth LTJ <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ NO.,a Length of linea R` Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS <br /> 11 Depth _ .Size <br /> Number <br /> SUMPS <br /> Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ ---- —T Property Lina <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 and regulations of the San Joaquin County <br /> Homs 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 she 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 t <br /> Certifies the following: "I certify that in the performance of the work for which this permit is issued, <br /> tion laws of California." I shat!employ persons subject to workman's compensa <br /> Ths applican at call for all requir d in pections. Complete drawing on-reverse 'de. T <br /> Signed Title: Y <br /> Date: — <br /> FO EPART NT <br /> Application Accepted by Date �� _ R-� <br /> Area <br /> Pit rou Inspection by Date `t Final Inspection by <br /> Data <br /> Additional Comments: P4:' ku (p7 r <br /> Applicant - Return all copies to: San Joa�C--_-tylic Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin; P O BOx 2009, Stkn, CA 95201 <br /> �FEE AMOUNT DUE AMOUNT REMITTED M�CASH <br /> RECEIVED BY DATEPERMIT'NO.EH 13•24 IREV. Q c3 c1EH u <br />