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I/ APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR <br /> (Complete in Triplicate) , <br /> ' 4 <br /> Application Is hereby made,to San Joaquin County for a permit to Construct and/or install the work herein described. Thio <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 /> v Job Address ` '((f5D City Lot Size/Acreage <br /> —!I� Owner's Name iiz �J Address/ Usr�� P�--- Phone <br /> s� f <br /> Contractor l/ �� J __Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION Ll Out of Service Well 0. PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER D Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private Cf Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ("1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CI Irrigation _.Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P.. State Work Done_ <br /> Well Destruction 0 Well Diameter Sealing Material & Depth M <br /> Depth Filler Material & Depth �\ <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION 0 REPAIRIAODITION 0 OESTRUCTIO I (No septic system permitted if public sower is <br /> t r>; vailable within 200 feet.) <br /> Installation will serve: Residence ^ Commercial_,".- Other <br /> Number of living units: Number of bedrooms14A water <br /> Character of soil to a depth of 3 feat: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity-- No. Compartments " <br /> PKG. TREATMENT PLT, 0 Method of Disposal , <br /> Distance to nearest: Well Foundation Property Line r <br /> f _ <br /> LEACHING LINE L1 No. & Length of lines E. Toia1 length/size V <br /> FILTER BED i_1 Distance to nearest: Well ` Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire " • Number <br /> SUMPS LI Distance to nearest: well' Y 3` Foundation I Property Lina i <br /> DISPOSAL PONDS © <br /> I hereby comity 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 wofkman'e Compensation taws 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." t' <br /> The applican must coif for all required inspgctions. Complete drawing on reverse side'. <br /> Signed Tide: —l�l�•fDate: <br /> FOR DEPARTMENT N USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date 'Fins I A nspection I— 7 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 BOR 2009, STOCKTON. CA 95201 <br /> FEE <br /> INFO AMO T DUE AMOUNT REMITTED CASH RITC IVCK I ED BY DATE PERMIT,NO. <br /> E Jj <br /> . tH 13•24 iREV.111%51 _[ <br /> EH:426 rs <br />