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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERRVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> MR—MIT EXPIRES 1 VE FR ld D TISSUED <br /> (Complete in Triplicate) <br /> Application is hereby wide to Sea Joaquin Count <br /> ° application is made in c Y for a permit to construct and/or install the work herein described. This <br /> J eegrliance xith San Joaquin County Ordinance Ho. 51+9 and 1862 and the Rules and Regula ed <br /> of San <br /> Joaquin County Public Health Services. r <br /> o- Job Address <br /> „r City Lot Slze/Acreage <br /> Owner's Name A Address F5 Phone <br /> '' „„ <br /> �7 a� <br /> Contractor ress �� <br /> �.. dLicense No. Q k� Phone <br /> TYPE OF WELL/PUMP: III NEW WELL ❑ WELL REPLACEMENT C7 <br /> DESTRUCTION Cl Out of Service Well <br /> PUMP INSTALLATION O SYSTEM REPAIR,❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> r SEWER LINES — plSp05AL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL -PITS/SUMPS <br /> INTENDED USE —PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I-) Industrial ti ❑ Open Bottom C1 Manteca is. of Well Excavation <br /> n Domestic/Private 0 Gravel Pack { ❑ Trac Dia. of Well Casing ^ } <br /> Tracy T ype of Casing_ Specifications <br /> Il Public .1 Other ❑ Delta Depth of Grout Seal Q <br /> I I Irrigation Ill A Type of Grout <br /> pprox, Depth I I Eastern Surface Seal lnstallod by <br /> Repair Work Done U Type of Pump H.P. r <br /> Well Destruction ❑ Wel! Diameter Sealing Material & Dept State Work Done <br /> 1. <br /> i - <br /> Depth miller Met <br /> ertil Ik Depth! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION pit <br /> c system permitted if public sewer is <br /> installation will serve; Rencemercial ` ava.ple within 200 feet.) <br /> Other <br /> Number of living units: � Number of bedrooms [ <br /> Character of sod to a ' ' s <br /> depth of 3 feat: Water table depth <br /> SEPTIC TANK. 0 I III /Mfg r <br /> PKG. TREATMENT PLT. ❑ _ Capacity Na. Compartments <br /> l <br /> `""�" Method of Disposal <br /> Distance to nearest: Well Foundation <br /> w 114 . I Property Line <br /> LEACHING LINE ❑.4. S Length of lines <br /> FILTER BED JP 1 r ' i s Total length/size <br /> 0 �Dis�ania to nearest:_ Well Foundation <br /> Property Line <br /> SEEPAGE PITS IJ Depth' t I <br /> v._ Siza Number <br /> SUMPS LI �pistance to ►►eilrast: Well ' <br /> DISPOSAL PONDS ❑ { Foundation_____ Property Lins. _ <br /> I hereby certify that I have pre <br /> 'pared 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 $an Joaquin County <br /> Homs owner or licensed agent'ssignature.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 m6nnar as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> the foNowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa f <br /> tion is alit nla E ill l <br /> The applicant c I for I. iced t n C plate drawing reverse aid <br /> Sig I J ` <br /> Title: .Q <br /> 1k t Date: At <br /> / <br /> FO DEPARTMENT USE ONLY <br /> Appli'Catlon Ccepted by <br /> r Date <br /> Pit or Grout Inspection by <br /> e, <br /> ��'i - Data�..,..�.,_, Final lnapeetion by�` Data {O <br /> Additional Comments: 1 <br /> APP1•1c&n•t-^-Return-aldll op1e9--to—San--Joaquin-County Pubite-Health--Sere-k"-a . <br /> . Environmental;-Health Permit/Services <br /> 445 N-San -Joaquin, P p'Box 2009, 3tkn, CA 95201 <br /> FEE AMOUNT''�DUE CK <br /> ` 3 AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERAIT,NO. <br />• EH M24(REV.1i46) � � r 1! ' <br /> rEH t..m ©� lug -� {'Z <br /> yZ <br />