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APPLICATION FOR PERS[I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES S . <br /> ENVIRONMIENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 (,v <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERM( T EgP I RES I Y FROM[ -RA TE S <br /> {Complete in Triplicate) /�JK <br /> Application is hereby made to Sea Joaquin Count foraruct <br /> application is made in ceegrliance vith San Joaquin County Ordinance No. 549aando1862eand�the eRulee and vork eRegulations of Sams <br /> J <br /> /oaquin County Public Health Services./ <br /> -1-5/16 Address <br /> City /t� Lot Slze/Acreage <br /> 'Awner's Name , LC f 1 LIF ' Address <br /> Phone G <br /> U,-eanlractor _ Address <br /> TYPE OF WELL/PUMP: License No. Phone <br /> NEW WELL ❑ WELL REPLACEMENT 1.1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ` OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ❑ <br /> ' DlSPOSAL�FLD. -PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS <br /> C7 Industria! 11 Open Bottom PROBLEM <br /> Manteca Dia. of Well Excavation ""VVV <br /> EI Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> C7 Tracy Type of Casing Specifications <br /> Il Public 171 Other n Delta Depth of Grout Seal <br /> I I Irrigation q Type of Grout <br /> ____ pprox, Depth I I Eastern Surface Seal Installed by r <br /> Repair Work Done U Type of Pump H.P. <br /> Well Destruction ❑ Well Diameter Sealing Naterial i Depth State Work pone <br /> Depth Tiller Material <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I DES TAUCTIO {No'se tic s slam <br /> —� P Y permitted if public sower is <br /> Installation will serve: Residence, Commercial„x �Other available within 200 feet.) <br /> -- <br /> Number of living units: Number of bedrooms <br /> Character of 501 to a depth of 3 feet <br /> SEPTIC TANK ❑f 'Type/fuHg ater table depth <br /> PKG. TREATMENT PLT. 0 Capacity No.Compartments <br /> od <br /> Distance to nearest: Well undation �. MethodOf Disposal <br /> Property Line <br /> LEACHING LINE ❑ No. & Length of it <br /> FILTER BED Total length/size <br /> ❑ Distance rest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ) Depth Sire <br /> SUMPS Number <br /> Ll Distance to nearest: Well Foundation <br /> DI AL PONDS p Property Line <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 /> Homo 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 1M performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Callf <br /> The applicant a call for required in ctions. Comple drawing on reverse side. <br /> Title: <br /> Date: <br /> �%OR�DEPA�RTPAENT�USE NLY <br /> Application Accepted by _ Sr, <br /> Date Area Z <br /> Pit Or Grout Inspection by Date t' <br /> ---�_ Final Inspection by Date VV <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 2000,. Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INfO CASH RECEIVED BY DATE AERVIMNO. <br /> EFS 11.24 tREV,i i e 51 / <br /> EH 14-26 ��� l i(7V � / �3 <br />