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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV IRONMFNTAL f1EALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR PROM DATE laaUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to cofwtruct 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 Services, <br /> XJob Address <br /> City _]ki_L_ Lot Size/Acreage <br /> 7? <br /> Owner <br /> /\ —1 ,—L, <br /> 11V,n 's Name' Address Phone <br /> XC ontractor Address- License No. <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT F-11 DESTRUCTION 0 out of Service Well D <br /> PUMP INSTALLATION LEI SYSTEM REPAIR D OTHER C1 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.__ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OT`,,ER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 177) industrial 0 Open Bottom C1 Manteca Dia. of Well Excavation—_ Dia. of Well Casing <br /> LJ Domestic/Private 0 Gravel Pack C] Tracy Type of Casing_—__ Specification <br /> M Public C.1 Other LJ Delta Depth of Grout Sea! __ Type of Grout <br /> 0 Irrigation — Approx. Depth D Eastern Surface Sail Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 7., CIESTRUCTION (No septic system permitted if public sewer is <br /> Aavailable within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: — Number of bedrooms <br /> Character of soil to a depth of 3 feel: --Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PILT, 0 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 C-) 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 0 <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 perlor,,nance 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 compensa- <br /> tion laws of California." <br /> The applicant must call for all required Inspections. Complete drawing on reverse side. <br /> Signed % Title: d Date, <br /> CR DEPARTMENT USE ONLY <br /> At— <br /> Application Accepted by Data 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 DIVISION PERMIT/SERVICES <br /> 445 X SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEECK III I <br /> MOUNT DUE <br /> INFO _AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT NO. <br /> .0 <br /> EH '426 <br />