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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 EXPIRE 1 Y FROM DAT <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 compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Pub*c Health Services. ;I <br /> i <br /> Job Addre City of Size/Acreage <br /> wner's Name <br /> o r <br /> Phone <br /> r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP-INSTALLATION-0 SYSTEM REPAI OTHER ❑ <br /> Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Iustrisl ❑ Open Bottum: ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' <br /> otic/Private ❑ Gravel Pack L3 Tracy Type of Casing Specifications <br /> I'1 Public fl Other n Delta Depth of'Grout-Sesl--_= tType of Grout <br /> '° i <br /> I I Irrigation Approx. pstern <br /> De I 1 'Surface Soul installed by I <br /> Repair Work Done U Type of Pump H.P.Seeling'Nate! State Work Done <br /> rial.A 'Depth <br /> Well Destruction ❑ Well Diameter 6 .� <br /> Depth T111er Material & 'Depthzi NO <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 400 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms - i <br /> Character of will to a depth of 3 feet: <br /> ' t l - -Water.tahle _depth <br /> SEPTIC TANK. ❑ Type/Mfg J, Cipacity -- -- ' �,-No. Compartments <br /> PKG. TREATMENT PLT.0 / ti C t Mettiod of.Disposal <br /> Distance to nearest: Well Foundation Pioperty_Lin* `-- <br /> LEACHING LINE �, D No. B-Length.of lines Total length/size f 5 ll <br /> ___-_FILTER_BED_!"i __.❑—Distance-10-nearest.--Well. - —Foundation.��...,-Property_Line-A - <br /> e� <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nsamst: 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 County <br /> Home owner or licensed agent's signature certifies the following: "t certify that in the performance of the work for which this permit is issued,1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of C 'Qualm." <br /> The applic at call for ad i ope4ions. Complete drawing onr eras 'de -/-7 <br /> Date: <br /> Sig Tit <br /> FOR DEPARTMENT USE ONLY tT•b <br /> CJ�wti C alt _ Date 4 1 Area b 2► r: <br /> Application Accepted by — <br /> Pit or Grout Inspection by Date Final Inspection by Date <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, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK A CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> t • EM 13-24 IeEV.i <br /> L4S .o e> ©® <br /> 220 L <br /> EN I�•7e <br />