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r., <br /> 4 APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV,�CES <br /> ENVIRONMENTAL HEALTH DIVISION F4./ t <br /> 0 P O BOX 2009, STOCKTON, CA 95201 " <br /> "- <br /> (209) 468-3447 AlC, <br /> PERMIT EXPIRES 1 YEAR PROM 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address y Lot Size/Acreage <br /> 5 � <br /> Owner's No Address o 7ri 6?'( one � <br /> License No. 4WPhone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMFl,,Pr 11 DESTRUCTION O Out of Service Well 0 <br /> PUMP INSTALLATIOf SYSTEM REPAIR O OTHER O 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 Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �mestic/Private O Gravel Pack O Tracy Type of Casing Specifications <br /> M Public Cl Other O Delta Depth of Grout Seal Type of Grout <br /> G Irrigation Approx. Depth * D 4stwn C � Surface Seal Installed by <br /> Repair Work Done U Type of Pump AC H.f}`-a State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth a4l Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms \ <br /> Character of toil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, Q Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> I 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: "1 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 laws of California." <br /> The applic must scall fo all irad in pgc4ions. Complete drawing on rillorse side-'o. <br /> Sig ��l�f/ 1 r Title' Date: <br /> FOR DEPARTMENT-.USE ONL - <br /> Application Accepted by Date_L._�" Area <br /> Pit or Grout Inspection by Date Final Inspection by fE) Date ` <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STUCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE /PERMIT NO. <br /> . EH 13.2 (REV. i n sl / \ <br /> EH 11.2 1i <br /> 4 Y (� `d`sl <br />