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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC 'HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, ICA 95201 <br /> (209) 468-3447 <br /> SIT EXRIRES 1 YEAR PROM 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 covilance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 4n <br /> Jab Address —�_��-1 ���,((� ,_,___, City 1F,-,AhLot Size/Acreage ,er <br /> Owner's Name ����/� Address Phone <br /> Contractor C' 2qQdress License No. �`�/ Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 0 Monitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial © Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public CI Other 0 Delta Depth of Grout Seal Type of Grout <br /> Cl Irrigation Approx. Depth Ll Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H,P. State Work Done { <br /> Well Destruction O Wel! Diameter Sealing Material & Depth v <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1:7 DESTRUCTION M (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence I— Commercial— Other <br /> Number of living units: Number of b dr oms, <br /> Character of soil to a depth of 3 feet: , Water table depth ` <br /> SEPTIC TANK Type/Mfy C Capacity No. Compartments <br /> PKG. TREATMENT PLT. ClI � Method of Disposal <br /> Distance to nearest: WellFoundation�Z Property Line <br /> LEACHING LINE No. & Length of lines l Total length/size I <br /> FILTER BED n Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS l Depth Size "f Number <br /> SUMPS LI Distance to nearest: Well r.' 'Foundation O Property Line " <br /> DISPOSAL PONDS Cl <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 reguiations 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 ha workman's compensation laws of Calilornia." Contractor's hiring or sub-contracting signature <br /> 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 compensa- <br /> tion laws of California." <br /> The applicant must calf for all required jr; ctions. Complete drawing on reverse side. /l <br /> Signed - Title: J� I". ,..,.. Date: _.2 " ✓y <br /> S,P ,,,�S" a`Cr�Y'�'-� �-c-.� '� <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted byDate Area <br /> PI or Grout Inspection b ata �� Final Inspection b Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN dOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY (SATE PERMIT'NO. <br /> INFO ly <br /> Eli <br /> �V 1l� .� I V ■V1 V <br />