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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 <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 coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County <br /> Public Health^ Services. <br /> Job Address T s > cgde• Ps-A, ___—_ ___ City Lot Size/Acreage U <br /> p �� <br /> Owner's Name � <br /> �" Address 7 Phone <br /> Contractor �f llit` ddressr�- "fC _�� , License No. `t9- � PhoneZ4-?-,=;l­ <br /> TYPE OF WELL/PUMP:-- ---- --NEW WELL O • --WELL REPLACEMENT 0 DESTRUCTIO Out of Service hell Gl <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHE ❑ Monitoring Well 0 <br /> DISTANCE TO 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 /> Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> rl Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public 1-1 Other (l Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth l I Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump ` H.P. __-Mato Work one <br /> Well Destruction D Well Diameter .�7-__ Sealing Material i Depth a✓ y1 pn� V <br /> a <br /> Depth lw� t biller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I l 1No septic system permitted if public sewer is <br /> f available within 200 lest.! <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines Total length/size t <br /> FILTER BED O Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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: 1 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 taws 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 laws of California." <br /> The applicant st tail or ell requ ed inspections. Complete drawing on reverse sifie. <br /> Signed Title: f [Z'GS. Date: <br /> R (D�E�PARTMENT USE ONLY ^7 _ <br /> Application Accepted by �._Qlaek _ _ f pays Date - Area Dy <br /> Pit or Grout Inspection by Date Final Inspection by ��( � Dats� �7 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, ?_- Box 2009, Stkn, CA 95201 <br /> FEE <br /> IN jO AMOUNT DUE AMOUNT REMITTED K ECEIVED BY ,RATE <br /> iT' <br /> TE aERMNO. <br /> t1•Id ✓ <br /> . EN 17.24 IREV,t/As)W! F 1f 1 i _ g <br /> EH L/ / <br />