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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 /> I ; <br /> PERULT EXPIRES 1 YEAR FROM DATE ISSUED � <br /> (Complete in Triplicate) <br /> Application in hereby made"to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cc4liance with San Joaquin,County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> E` Joaquin County PublicHealth a rvicea. <br /> iE <br /> t <br /> k0b Address "� a City Lot Size/Acreage <br /> Owner's Name A Address Phone <br />!' Contractor Address License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ f WELL REPLACEMENT 0 ,r DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION•❑ + SYSTEM REPAIR ❑ OTHER ❑ . Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -: DISPOSAL FLD. - PROP.,LINE <br /> �f —FOUNDATION'- AGRICULTURE WELL ' OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />! ❑ Industria! ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> n Domestic/Private ❑ Gravel Pack ❑ Tracy . Type of Casing_ Specifications <br /> l'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout r <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Said Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction D Well Diameter Sealing Material i Depth <br /> Depth Miler Maters th <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITI DESTRUCTION lNo septicm permitted it public sewer is <br /> ave within 200 feat.) <br /> Installation will serve: Residence_ Commercial_ Othe W <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of:3 feet: 4 a depth <br /> SEPTIC TANK. ❑ Type/Mfg Cspacit No. Compartments <br /> PKG. TREATMENT PLT.❑ IP Method of Disposal <br /> Distance to nearest: WelkFoundation _ — Property Line <br /> LEACHING LINE ❑ No. f1, Length of lin - Total length/size <br /> FILTER BED ❑ Distance to eat Well Foundation Property Line <br /> I <br /> SEEPAGE PITS 11w'0ept11n Size Number <br /> SUMPS - _LI Distance to nearest: Well Foundation Property Line - <br /> DIS1P03/KC-F$bNDS ❑ <br /> I haroby 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 f a <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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa=' ' <br /> tion laws of California." <br /> T ppf" ust call-for ail req 'ed.inspections. Complete drawing on reverse side. <br /> I w f a le: �t.tan.,✓�. Date: <br /> R DEPARTMENT USE ONLY <br /> p Application Accepted by i y Date 13 Area <br /> Pit or Grout Inspection by Date Final Inspection by Dat 11' �✓ <br /> Additional Comments: <br /> IApplicant - Return all copies to: San Joaquin County Public Health Services <br /> i Environmental Health Permit/Services <br /> I! 445 N San Joaquin, P 0 Box 2009, 3tkn, CA 95201 <br /> 1 <br /> INFO AMOUNT DUE AMOUNT REMITTED K ECEIVE BY DATE PERMIT'NO. <br /> I �rJ <br /> I . EN M21(REV.1/�5!� // .�i � yr�� q3 <br /> t Ex 14.18 <br />