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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> Y <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the vont herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> JoaquinC unty Public Health S rvicee. <br /> r City t Size/Acreage <br /> Jab Addr as <br /> Owner's Name � 7717- !r Address Phone <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT, 0 DESTRUCTION ❑ Out ofi <br /> Service Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 Industrial ❑ Open Bottom D Manteca Die. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public C7 Other 0 Delta Depth of Grout Seat Type of Grout <br /> CC Irrigation ...._,Approx. Depth 0 Eastern Surface Soul Installed by t �� <br /> Repair Work Done U Type of Pump H,P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material k Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0 DESTRUCTION G INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Re 'dente X Commercial— Other [� <br /> Number of living units: Number rooms-7 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK X Type/Mfg Capacity Z�oNo. Compartments <br /> PKG. TREATMENT PLT. Cl Method ofDisposal <br /> Well Distance to nearest: WelFoundation ZZ2 PropeRy Line <br /> LEACHING LINE No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Z 6725; Foundation Property Line <br /> SEEPAGE PITS Depth -Sire <br /> J Number <br /> SUMPS LI Distance to nearest: Well f5:�P j Foundation Property Line <br /> DISPOSAL PONDS 0 <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 /> 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 compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies th•following: "I certify that in the performance of the work for which this permit is issued. I shall employ persons subject to workman's compensa- <br /> tion Iowa of California." <br /> The applicant must i fo quired inspections. plate awing on r arae side. <br /> /57 <br /> Signed Title: <br /> E/ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date 0 <br /> Application Accepted by <br /> Area <br /> th: <br /> Pit r Grout lnspoetion b Oates Final Inspection b Date/ <br /> Additional Comments: — <br /> i Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201. <br /> FEE AMOUNT DUE AMOVNT REMtTTEO CI( RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH I I <br /> . E„1,:224 IItEV.r i 51 <br />