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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 vork herein described. This <br /> application 1s made In compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Publil HejLlth Services <br /> Job Address c Cit Lot Size/Acreage <br /> O ner's Na 1e -°L �_Jl1l/�r-r Addrtrss Phone <br /> / ✓` 7 <br /> ra Phone <br /> �re � Lic se No. <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEM NT O DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATIOSYSTEM REPAIR O OTHER O Monitoring Well n <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 /> 1Istrisl O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> a: estic/Private O Gravel Pack O Tracy Type of Casing_ Specifications <br /> 1 Public f.l Other n Delta Pepth of Grout Seal Type f Grout <br /> I I Irrigation Approx. De I Eastern /Mace <br /> Seal Installed by44a <br /> Repair Work Done U Type of Pu ` H.P. State Wor <br /> We# Destruction O Well Diameter Sealing Material i Depth <br /> Depth /(/ Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other 1 <br /> Number of living units: Number of bedrooms �J <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line �! <br /> LEACHING LINE C) No. a Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 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 N <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 sub-contracting signature <br /> certifies the foNowing: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion Iww of CoWornis. <br /> " <br /> The applic t 1 st cal red i "ptions. Complete drawing on ores i e. �} <br /> Tit l Date: <br /> FOR DEPARTMENT USE ONLYA �J <br /> Application Accepted by 'W' Dots IV Area ?l <br /> Pit or Grout Inspection by Date Final Inspection by c //,,d,(_ Date <br /> r <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 /> INFO I <br /> % 'AMOUNT DUE AMOUNT REMITTED CASH <br /> CK RECEIVED 9Y yDATE PERMIT'NO. <br /> . EH 13-24(REV.l i n al � 16 1 0 0 <!5,�� 0 �DN2 3 1 <br /> EH 14.36 11 <br />