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xw�, <br /> g APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY" PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR <br /> 3$'6 00 S W, (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 cosopliance with San Joaquin <br /> Joaquin County Public Health Servicsa.__ County Ordinapca No. 549 and 1862 and the Rules and Regulations of San <br /> �C) <br /> Job Address <br /> +• --. , City Lot Size/Acreage <br /> Owner's N&MV Address <br /> Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ <br /> fL PUMP INSTALLATION C} SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST; SEPTIC TANK _ SEWER LINES DISPOSAL FLD.A�4_ PROP. LINE <br /> FOUNDATION . AGRICULTURE WELL OTHER WELL., PITS/SUMPS <br /> INTENDED USE T F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial p Open Bottom Manteca Dia. of Well Excav Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ 7ra Ty s+ng Specifications <br /> M Public is Other 0 Delta of cw"04trm Type of Grou <br /> Gf Irrigation —..ApproK, Depth ern Surface Sea Iled by rr� <br /> Repair Work Done 0 Type of Pump H.P. a Work Done _ <br /> Well Destruction ❑ Well Dia or Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR JADDITION L1 DESTRUCTION G.INo septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> Installation will servo: Residence_.,, mmerclel Other_ <br /> Number of living units: Number of be s <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments C <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Dist a to nearest: Well Foundation Property Line # <br /> LEACHING LINE C1 No. & Length of lines- Total length/size r (� <br /> FILTER BED f 7 Distance to nearest; Foundation Property Line ll' <br /> SEEPAGE PITS I I Depth Siie <br /> Number <br /> SUMPS L1 Distance to nearest: Foundation Property 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 /> 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 /> Omploy 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 permi is &A I-"Al employ persons subject ta.,e��•>man's compenaa• <br /> flon Iowa of California." <br /> -The applicsnt-must al( for all required inspections. Complete drawing on reverse side, <br /> Signed * Title: fDate <br /> : <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by ? Ie-2 <br /> L_4p r Q <br /> Date Area �J <br /> Pit or Grout Inspection byDate 6�si+�rv�G 4,= 3 <br /> Final Inspection by r4 0 .�6s pate OZq a <br /> �7Fra�.r f sPc ra <br /> Additional Commence: <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 B 2008, STUCKTON, CA 85201 <br /> FEE <br /> OUNT DUE AMOUNT REMITTED CK <br /> NFO RECEIVED BY <br /> I �jCrgn NQ DATE PERMIT'NO. <br /> EH 12�IREV.iia+ss <br /> ;{•4. <br /> EH 2e <br /> t <br /> �,Z <br />