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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 M <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with Elan Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Colony Public Health Services. <br /> r Lot Size/Acreage <br /> Job Address Cit <br /> Owner's Name Address Phone <br /> Contractor ' _Address �'' ' � ense No, Phone <br /> TYPE OF WELL/ UM :: NEW WELL C1W <br /> WELL REPLACEMENT El DESTRUCTION ❑ Out of Service e ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR CI OTHER l Monitoring Well ❑ <br /> _ I <br /> "- DISTANCE TD 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 /> Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing_. Specifications <br /> V] Public Cl Other FI Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation . Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ( Type of Pump-.A"A— H.P. I State Work Don r <br /> Sealing Material 0 Depth <br /> Well Destruction ❑ Well Diameter ti <br />` Miler Material i Depth <br /> Depth <br /> k TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I 'No septic system permitted if public sewer is <br /> available within 200 feet.) L f <br /> Installation will serve: Residence_ Commercial— Other 4{ ] <br /> I <br /> Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of 3 test: Water "YMENT <br /> SEPTIC TANK -:,, ❑ Type/Mfg Capacity .Nv. Com <br /> I PKG, TREATMENT PLT. ❑ _ f 1, Method o rAxIvr <br /> Distance to nearest: Well Foundation _,Property Line n � <br /> - � � � ? ' <br /> I LEACHING LINE ❑ No. a Length of lines Total lengthlsize <br /> FILTER BED ❑ Distance to nearest. Well Foundation Propert� 1�W,%­- -- Wf- <br /> SEEPAGE PITS 11 Depth Size Number _ <br /> - - -� <br /> Pr <br /> --SUMPS-: ' r"` LI'Distanca tv neire:t:� Wall -�- Foundation " operty�Line <br /> DISPOSAL PONDS ❑ z <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 /> 3 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 shall not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> i canities the following:"I certify that in the performance of the work for which this permit is issued,l&hall employ pentons subject to workman's compensa- <br /> tion laws of Californis." <br /> " The applicant must call for all equicad inspections. Complete drawing on reverse side. <br /> Sign * Title: Date: <br /> d FOR <br /> !! Application Accepted by Dots 15eraa <br /> Pit or Grout Inspection by Date Final Inspection by Dote <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Service® <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED A RECEIVED SY DATE PERMIT'NO. <br /> INFO f <br /> c . EH13-2411MV.ties <br /> fH 14.28 <br />