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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DAZE ISSUED <br /> (Complete in Triplicate) <br /> •i <br /> Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in ecelpliance 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 _y Phone _ <br /> Contractor Address se.No. J.2f Phone 7_ 2 <br /> TYP WELL/PU P: NEW WELL ❑ WELL REPL CEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> c� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ MonitorWell n <br /> D ANC RESS <br /> T: SEPTIC TANK SEWER LINE , DISPOSAL FLD.' �" PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECtFICAT,eS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation `T�j—�/C6f Dia. of Well Casing ` <br /> * Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ r Specifications l�f <br /> el"El-.Public rl Other Cl Delta Depth of Grout Seal 0 Type of Grout <br /> I I Iffigation _.Approx. Depth I I Eastern Surface Seal Installed by o a <br /> Repair Work Done U Type of Pump H.P. State Work Done "� ! <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth biller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewar is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> -'Number of living units: 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.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE LI No. 6 Length of lines Total lengthtsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI 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 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cartifias the following: "I certify that in the dormancs of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of r <br /> The appy an r all uir i coon -Complete drawing on re a side. <br /> Signed Title: Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by " Date <br /> Pit or Grout Inspttction by Date Final Inspection Datf <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 O Box 2009, Stkn, CA 95201 <br /> IN 0 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE[y PERMIT�NO. <br /> • <br /> EH%4-26 <br /> 4 SCA- <br /> W , 1 1 f d f <br />