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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 0 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 Public Hgal Services. <br /> Job Address �`� p City '5,A Lot Size/Acreage <br /> Owner's Name w "°"ted Address �� ��( Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well O <br /> DISTANCE TO NEAREST: SEPT SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom O Manteca Dia. ell Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casin _ Specifications <br /> ('1 Public -1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done - <br /> Well Destruction O Well Diameter Sealing Material • Depth <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> ,tel <br /> Installation will serve: Residence A Commercial ther yj,� rte t <br /> Number of living units: Number of bedrooms_ <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 f s'f f�(� TO O<- Method of Disposal <br /> Distance to nearest: Well Foundation Property line <br /> LEACHING LINE CI No. b Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Founded n Property Line <br /> �- <br /> SEEPAGE PITS 11 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 <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 following:Lcothat in the performance of the work for which this permit is issued,1 shall employ persona subject to workman's compensa- <br /> tion laws of CaliforniaTrhge applicant must ufr �ne, Cpmpl a dr ting on reverse side. '� <br /> Signed ite: Date: <br /> FOR DEPARTMENT USE ONLY -7 / <br /> Application Accepted by Date / Area <br /> Pit or Grout Inspection by Date Final In ctt n by Date <br /> Additional Comments: j <br /> Applicant - Return all copies to: San Joaquin County Public fiealth Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RE(C�EII/VED BY ID(A�TEA PERMIT'NO. <br /> 71. EM14•24(NEV. i M 51 / ✓ ") � Gam✓ [ l l �� <br /> EM t1•aD c <br />