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APPLICATION FOR PTRII[I T <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 ESPIRES 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 Health Sery ces.� <br /> Job Address City Lot Size/Acreage <br /> Owner's Name a Address Phone 7 f � <br /> Contractor dress cense No.� Phone <br /> ZZL/A�L� <br /> TYPE OF W LL/ UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well O <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 Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [l Domestic/Privet* O Gravel Pack ❑ Tracy_ _Type of Casing_ Specifications <br /> I'1 Public I'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 Materiali th <br /> Depth Filler Material Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION F1 DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence I Commercial_ Other <br /> Number of living units: ___I. 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 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. IN Length of lines J4 To t81 length/si:e <br /> FILTER BED O Distance to nearest: Well/ <br /> FoundationtProperty Line <br /> SEEPAGE PITS 11 Depth AX 7" ''- Number <br /> SUMPS LI Distance to nearest: Well 1 p() - Foundation d 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: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss- <br /> tion laws of California." <br /> The appliean s 11 or all tr inspections C plate drawing on re arse side. <br /> Signed Title: ` Data: <br /> NT USE ONLY *� <br /> Application Accepted by -4., Date 1�^l� Area <br /> i <br /> 6or Grout Inspection by at Final Inspection by� A 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 0 Box 2009, Stkn, CA 95201 <br /> IEEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT"No. <br /> EN 14.26 11EV.,,ns� �0­z, 117-0 3 73-1 <br />