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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 EXPIRES 1 YEAR FROM DATE ISSUED <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 1862 and the Rules and Regulations of San <br /> Joaquin County Pu lic HealthServiic�ces.n 1 �� <br /> Job Address A 1��1 r 1 r� City Lot Size/Acreage <br /> Ow is Na��T ,` E��t"'v Address 66� Phone ~ <br /> �I �, s <br /> OR, a t"ora' " ' s ���`� ense NA_b(�2Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMEN f_l DESTRUCTION ❑ Out of Service well O _ <br /> PUMP INSTALLATION O SYSTEM REPAI OTHER O <br /> Monitoring well ❑ <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 /> 0 dustrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> otic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> Il Public f:l Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Oeptfi astern Surface Seal Installed by AD/ <br /> Repair Work Done U Type of Pu H. State Work Done f <br /> Well Destruction O Well Diameter Sealing Materiel & Depth <br /> Depth Filler Material i Depth 10 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septtilablec syst m permtreated if public sewer is <br /> avaInstallation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 fest: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby certify that 1 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 /> Horne owner or licensed agent's signature certifies the following: "I 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 sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compense- <br /> tion laws of Californ <br /> The applicant t call for ► uired inspections. Complete drawing on rev side. <br /> Af <br /> Sig TitleDate: <br /> FODEPARTMENT USE ONL <br /> ,.• C` �.. <br /> Application Accepted by � - �^^ < '�`%L` Date _ L ' Area <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 O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CA;S#H RECEIVED BY DATE PERMIT'NO. <br /> INFO /} <br /> 1124INEV.hest <br /> 4.26 I_ �+ <br />