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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' t° <br /> ENVIRONMENTAL HEALTH DIVISION f <br /> P 0 BOX 2009, STOCKTON, CA 95201 MAY <br /> (209) 468-3447 CA]ViRON <br /> MENTAw HEALTH <br /> PERMIT EXPIRES 7 YEAR FROM DATEI_SSIIM PERMIT/SERVICES <br /> (Complete in Triplicate) <br /> Application in hereby made,to San Joaquin County for a permit to construct-and/or install the work herein described. This <br /> application is atade in ecupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _3:5-03 - _ City Lot Size/Acreage <br /> Owner's Name Address Phone <br /> ConlractoAddress � License NodT-42-- Phone-S'1_-_A4W <br /> TYPE OF WELL/PUMP: NEW WELL 0 g , WELL REPLACEMENT F-1DESTRUCTION ❑ Out of Searing Well C1 <br /> PUMP INSTALLATION [ � SYSTEM REPAIR Gl— OTHER Q Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Indatrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Oomestic/Private ❑ Gravel Pack L7 Tracy Type of Casing Specifications <br /> ❑ Public fa Other © Delta Depth of Grout Seal Type of Grout <br /> Ci Irrigation --'�.Approx. Depth ❑ Eastern Surface Seal installed by <br /> Repair Work Done 0 Typo of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material i�Depth <br /> l <br /> Depth Filler Material—& Depth. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAtRIADDITION CI DESTRUCTION GI !No septic system permitted if public sewer is <br /> available within 200 leet.1 <br /> Installation will serve: Residence^ Commercial— Other <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 /> PKG. TREATMENT PLT,C] Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines ` Total length/size <br /> FILTER PIED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS Irl Distance"to nearest: Well' Foundation Property Line <br /> DISPOSAL PONDS 0 s <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: "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 subcontracting signature <br /> certifies the following: "I certify thotin the peiiormance of'the work for which this permit is issued; I-shall.employ persons subject to workman's compensa- <br /> tion laws of California." .I <br /> } <br /> The applicant must ca all required inspections,,Complete drawing on averse side. <br /> Q <br /> Signed x— T Title: Data: `'� L <br /> FO DEPARTMENT USE ONLY / r� <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date l� <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 BOX 2005, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMIT'TEO CK RECEIVED BY DATE PERMIT'N0. <br /> INFO /� CASH <br /> r EH 13•21[REV. /nSl ,R � <br /> V f9 � Al <br />