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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 /> PERMIT EXPIRES 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 ccnpliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Cro�ti�tuU Public Health Services. �l <br /> �� Lr�Z�_ ����✓/ Cit Got Size/Acreage <br /> Job Ad <br /> dress Y <br /> Owner's Name -� Address ��'f Phone <br /> Conhacto Address W J. License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REP ACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring well [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDPROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELE�.^ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICAT12NS r <br /> n industrial ❑ Open Bottom ❑ Manteca Oia. of Well Excavation es Dia. of Well Casing <br /> %dDomeslic/Priv8te 4 Gravel Pack I7 Tracy Type of Casing Arc Specifications <br /> M Public (I Other ❑ Delta Depth of Grout Seal �� __- Type of Grout - <br /> CI Irrigation -4prox. Depth 0'&Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i•Depth v <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION C1 DESTRUCTION G (No septic system permitted if public sewer is W <br /> available within 200 feet.) �[ <br /> Installation will serve: Residence— Commercial? Other -� <br /> Number of living units. Number of bedrooms f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, Q Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 taws, 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 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 Iowa of California." <br /> The applicants f all uired inspections, Complete drawing on arse sid - .- <br /> Signed Tit _ Date: <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by Date ,1=�—ro Area- <br /> Pit o , sou Inspection tty / Date v Final Inspection by 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 JOAQUIN, P 0 HOS 2008, STOCKTON, CA 95201 <br /> FEE <br /> INFO AM�OUNT DDUEtAMpUNT REMfTTED CASH RECEIVED BY DATE PERMIT'NOO. <br /> C <br /> . EH r3.7�ileEv.��+er �-4 �O T;i,?�ar' L -Skp <br /> EHAV <br />