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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOB 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YE 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 compliance with San Joaquin County Ordi c o. 5 and 1862 d the Rules a.nd'Regul.atione of San <br /> Joaquin County Public Health Services. <br /> CC���Job Address � Z� City Wt Size/Acreage <br /> -Imps Name res Phone <br /> On r <br /> ��Ss ense No. Phone v 3 3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATIOSYSTEM REPAIR CIOTHER O monitoring Well n <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL �" OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I- dustrial ❑ Open Bottom ❑ Manteca Dia. of Welk Excavation Dia. of Well Casing <br /> stie/Private Cl Gravel Pack C1 Jracy 4 Type of Casing_ Specifications <br /> I'I Public -i 1 Othaf""°'" """"'�fl-Delta--^^^^,-Depth of-Grout-Seat Type-of-Grout ---- -- <br /> I I Irrigation �.Approx. DSel I Ea n [Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done r <br /> Wall Destruction ❑ Well Dia t Sealing Material i Depth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION'I I DESTRUCTION l I INo septic syslem permitted if public sewevis <br /> available within 200 feet.) k <br /> Installation will terve: Residence_ Commercial— Other <br /> Number of living unity: ' Number of bedrooms { <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.0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE r Cl No, a Length of lines Total length/size <br /> FILTER BED p..Distance to nearest: Well Foundation Property Line r' <br /> SEEPAGE PITS I Depth Size ""*"-" Number <br /> SUMPS LIQ Distance to nearest: Well Foundation Property Line . <br /> DISPOSAL PONDS ❑ # <br /> I hereby Certify that I have prepared this application and that the work will ba 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 thatin tthe performance cf 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." Contrsi tor's hiring or suli-dontracting signature <br /> certifies the following: " certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's companss- <br /> lion laws.oPeAfornis., + <br /> The appli st call r all u ad in tans. Complete drawing on verse side:, <br /> SpAA Date: <br /> FOR DEPARTMENT USE ONLY0 <br /> .r <br /> Application Accepted by _ Date Ar a4 <br /> Pk or Grout Inspection by Date t Flnal Inspection.by- Date <br /> Additional Comments: <br /> Applicant- Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P ox 09, Stkn, CA 95201 <br /> iFEE AMOUNT DUE AMOUNT REMtTTEt) CASH EIVED BY D TE PERMIT-NO. <br /> . EM 112 1RtV:r i R `I<1 <br /> EH tC26 l�► �/ / <br />