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{ <br /> APPLICATION FOR PERMIT � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION t <br /> 43LO9 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 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 coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name Address ��1'`r� Phone ~ <br /> Contractor ress rfsR'iKo• r2�_Phone <br /> TYPE Of WELL/PUMP: NEW WELL WELL REPLAC MENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring well l ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK----- SEWER LINES DISPOSAL FLD.. PROP. LINE v�r <br /> FOUNDATION rr�� AGRICULTURE WELC:= OTHER WELL PlTSI5UMPS_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 Industrial O Open Bottom El Manteca Dia. of Well Excavation Dia. of Well C$ ink <br /> 14 j&ed <br /> mastic/Private `(�Cravel Pack Tracy Type of Casing Specifications <br /> sPu rc Olher"� "` "n Delia ""'�`Depth of Grout Seal '-'Type of Grou <br /> �Ir tImion �Approx. Depth I I Eastern Surface Seal Installed by (;�►t-( <br /> pair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction O Weil Diameter Sealing Material i Depth <br /> Depth Filler Material A Depth Kilo. Fill his-, <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIA/ADDITION I I DESTRUCTION I I (No pgptic system permitted if public sewer is: <br /> available within 200 feet.) <br /> Installation will nerve: Residence— Commercial_ Other �. <br /> Number of living units: Number of bedrooms w i <br /> Character of soe to a depth of 3 feet: ! Water table depth �} <br /> SEPTIC TANK ❑ Type/Mfg Capacity i No. Compartments <br /> PKG. TREATMENT PLT, ❑ -- Method of Disposal <br /> Distance to nearest: Well Foundation • IProperty Line <br /> F <br /> LEACHING LINE 0 No. m Length of linea k Total length/size <br /> r <br /> FILTER BED ❑ Distance to nearest; Well Foundation Property Line { , <br /> SEEPAGE PITS I.I Depth Size r Number <br /> "aSUMP5 �°' '"'Ll' Distance io rleare:t:• —V1'lell T -Foundation " - '"-Piope1ty line „` <br /> DISPOSAL PONDS ❑ <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 /> Homs owner or licensed agent's signature certifies the following: 1 certify that in the performance of the work for which this permit is issued,-I shell 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*hall employ persons subject to workman's eompensa- <br /> tioh,4ws of California. <br /> The sppli Ti u 1 or ell rit inspections, Complete drawing on r rae sidaf . <br /> SignedTitle: Date: 3D <br /> FOR DEPAR MENT USE LY <br /> Application Accepted by Date Area <br /> } <br /> Pit or Grout Inspection by note Final Inspection by <br /> Date <br /> Addhional Comments: 0 34 ' <br /> I Applicant - Return all copies to: 3a Joaquin County Public Health Services F <br /> �uzcT= ��-' Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 <br /> F <br /> INE AMOUNT DUE AMOUNT REMITTED K ECEIVED BY D TE PERMIT'NO. <br /> O/ <br /> EN 11-]a /// <br />