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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVcrsf I ECE I VEE D <br /> ENVIRONMENTAL HEALTHDIVISION <br /> P 0 BOX 2009 STOCKTON' CA 95201 S E p 9 1991 <br /> (209) 468-3447 <br /> ENVIRONMENTAL HEALTH <br /> .P,MIT EXPIRES 1 YEAR OROldf DATE ISSUED FERMI i/URVi�.rr".`S <br /> (Complete in Triplicate) <br /> Application is hereby alade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> ayplication is glade in co�liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I <br /> Job Address City Size/Acreage <br /> t <br /> Owner's Name Address Phone <br /> Contractor' Address 3o )cense N Phone L <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Nell Ll <br /> PUMP INSTALLATION 0,--' SYSTEM REPAIR i f OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES L IDISPOSAL FLD. PROP. LINE <br /> C FOUNDATION 'AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL '" `PROBLEM AREA _ CONSTRUCTiON SPECIFICATIONS <br /> F1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications_._. _ <br /> Cl Pub!!c I-1 Other ❑ Della Depth of Grout Seal Type of Grout ... <br /> G Irrigation Approx. Depth '❑ Eastern Surface Seal Installed by <br /> Repair Work Done jJ' Type of Pump H.P. State Work Dona <br /> f Well Destruction O Well Diameter Sealing Material & Depth nn� <br /> Depth Filler Material A Depth y� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION L"I DESTRUCTION CI 1Noseptic system permitted if public sewer is l <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other ` <br /> m"—Number ot-living-unite:-- ,Number-of..bedrooms. _ 4- <br /> Character of soil to a depth of 3 feet: Water table depth -- <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No._&.Length-gf.Jines--..-.-.--- Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line i <br /> SEEPAGE PITS 11 Depth Site Number <br /> SUMPS L'I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ' <br /> ! 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 comity 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 subcontracting signature <br /> certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa• <br /> tion laws of California" <br /> The applicant a!I raquiratl' pections. Complete drawing on verse side: / <br /> Signal Title: <br /> Date: <br /> FCM. DEPARTMENT USE ONLY J <br /> Application Accepted by DateArea <br /> Pit or Grout Inspection by ate Final Inspection by�PL pate 9 f(a �/ <br /> Additional Comments. <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PEREEIT/SERVICES � <br /> 445 N SAN JOAQUIN, P 0 SOX 2009, STOCKTON, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y <br /> INFO CASH DATE PERMIT NO. <br /> • EH 1344IREV.rinSr lR"", <br /> EH ii•$e ` �r . <br /> I <br /> y <br />