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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />` ENVIRONMENTAL HEALTH DIVISION <br />,�. P 0 BOX 2009, STOCKTON, CA 95201 <br /> (249) 468-3447 <br /> pEMTT XMIRES 1 YEAR M <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application to made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. C <br /> Job Address 2– -4--Z��0 L I City Lot Sire/Acreage <br /> Owner's Neme�v�G �Y,4,gnrAddress A/* Phone <br /> �,, x'f �✓ 17�.� License No 7?of Phoney <br /> Caniracto ��'� O `�" Address <br /> TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT Q DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well G7 <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 /> e <br /> fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> omestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications Yd�� <br /> M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout t { s <br /> 0 Irrigation Approx. Depth b Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump t'JI H.P. 3 _ State Work Done <br /> ! Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ZT DESTRUCTION G lNo septic system permitted if public sewer is <br /> available within 210 feet.l <br /> Installation will serve: Residence — Commercial— Other <br /> Cn <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments <br /> PKGeITREATMENT PLT, 0 Method of Disposal j" C <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS LI 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 laws, and , <br /> rules and regulations of the San Joaquin CouAy <br /> Homs 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 perfotmance of the work for which this permit is issued, [.shall employ.persons subject to workman's compenss- <br /> tion laws of California." ` <br /> The applicant must coA for all required inspections. Complete drawing on reverse side. <br /> Signed X �`� Title: �` Date: <br /> 5 <br /> R DEPARTMENT USE ONLY <br /> _Application Accepted by w _ sate "� Area <br /> Pit or io Inspection b; Date C1 . f3..4 Final inspection by,_JC:CPA <br /> !� -- <br /> Additional Comments: `` <br /> Applicant » Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> I 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95201 <br /> t FEE AMOUNT DUE AMOUNT REMtTTEO CK <br /> p, <br /> RECEIVED BY DATE pERMl1 NO. <br /> INFO CASH �j <br /> . EMm3-T41REV,�in{1 3 t7-D �� lJ� T` <br />