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APPLICATION FOR PERMIT ,� f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES No <br /> r ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 No <br /> (209) 468-3447 <br /> PERMIT ESP ES 1 YEAR_ OM DATE ISaUED <br /> (Complete to 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 couplience with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Joh Addra City�. Lot Size/Acreage <br /> Owner's Nama Address ' <br /> Cont+actor Addres Y License Phone <br /> TYPE OF WELL/PUMP. i NEW WELL❑4 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well C1 ' <br /> l' PUMP INSTALLATION f� SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK �'` SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE 01: WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! <br /> n lndustrial O Open Bottom ❑ Manteca Dia. of Well Excavation DiZf Well Casing <br /> -L)-Oomestic/-P.rivate y ❑ Gravel Pack:. ❑•Tracy Type of Casing 5pecilications i <br /> M Public! C1 Other 0 Delta Depth of Grout Seat Type of Grout r <br /> 0 IrfiUation i Approx. Depth © Eastern Surface Soul Installed by f <br /> RepairWork Done L]. Type of Pum H.P. -.-.---. __ -State.Work-Done_ $ <br /> Well Destruction 01 Well Diameter t Sealing Material i Depth <br /> Depth t t r Filler Material i Depth i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L) REPAIR/ADDITION 0 DESTRUCTION EINo septic system permitted it public sewer is <br /> `available within 240 feet.l <br /> Y Installation will server •Residence f Commercial Other <br /> Number-of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet r Water table depth <br /> SEPTIC TANK. • �X Type/Mfg Capacitya(4—&22- No.,Compartments <br /> r <br /> PK ATMENT PLT:0 � �. _ Method of Disposal l <br /> Distance to nearest Well Foundation- Property Line <br /> LEACHINGLINEl i 0— No. & Length' of tines Total length/size <br /> t0 _ <br /> FILTER BED t 0 Distance to nearest: Well Foundation Property Line <br /> L �: { <br /> �r- <br /> SEEPAGE PITS' 'I I Depth I Sire Number <br /> SUMPS EiL1 Distance toYnaarest` WaH Foundation F Property Line i <br /> DISPOSAL PONDS ±0 -_ <br /> I hereby certify that I have prepared this appficatipn 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 1-1 1 <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 sub-contracting signature <br /> certifies the following: "E certify that in the performance of the wc44or which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California.' <br /> The applicant, c I all q d insWpOopircomplete drawin 'averse side.*.. <br /> Signed r Title. a ` Date. <br /> FOR pEPART. <br /> ART? ONLY <br /> Application Accepted by -x � :: 1t Date �' L 1_ Area <br /> �+ <br /> Pit or Grout Inspection by Date Final Inspection by Data J <br /> Additional Comments: - <br /> 3 <br /> Applicant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I� ENVIRONMENTAL.HEALTH AI-VISION PERMIT/SERVICES <br /> r 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> CAS►1 RECEIVED BY DATE PERMIT'NO.r <br /> IEEE <br /> i . EK 13.24IREV.rin5+ ��{_ba r34 - �• � I����j�l <br /> it EM 3620 r <br />