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I ADPL I CATIwe.ON FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH .DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <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 Ordinance No. 549 and 1$62 and the Rules and Regulations of Sen <br /> Joaquin County Public Health Services. <br /> Job Address 0 City r Lot Size/Acreage <br /> Owner's Name Address AIL Phone <br /> Contractor Address12q?Z2­5;-:7 CLicense No / v Phone <br /> TYPE OF WELL/PUMP. NEW WELL 0 WELL REPLACEMENT M DESTRUCTION 0 Out of Service well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER C Monitoring Well C7 <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 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of.Well Casing <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public Cl Other :i � ❑ Delta Depth of Grout Seal Type of Grout <br /> >I;Irrlgation 4+ Approx, O�epth CIA astern Surface Seal Installed by ' <br /> Repair Work Done 'Type of Pump,/— H,P. State Work Done c`^ <br /> Well Destruction © Well Diameter Sealing Material i Depth• _ ' <br /> Depth 'i Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEWINSTALLATION 0" REPAIR/ADDITION 0 DESTRUCTIVE (Na septic system permitted if public sewer is C <br /> Qvaijbtils within 206 feet.! <br /> Installation will serve: Residence Commercial Other r <br /> Number of living units: Number of bedrooms ,wJ <br /> Character of soil to a depth of 3 feet: Water water table depth s <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl ' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE �. Cl``No. S Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS .rte LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ u ' <br /> I hereby certify that I have prepared !his applicaficin 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 s <br /> Home owner or licensed agent's signature certifies the following: "I-certify;thai 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`;workmsn'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 shall employ persons subject to workman's ompe sa• <br /> tion laws of California." ik J�•a, `N <br /> Th plieant st cell for all require speedo . Complete dr wmg on reverse side. <br /> Signed Title: — Date: <br /> 01 14 <br /> NT._.USE ONLY <br /> Application Accepted by Date �j'1-14—" Area G] <br /> Pit or Grout Inspection by Date Final Inspection by f r Date �� f <br /> Additional Comments: <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 BOX 2008, STOCKTON, CA 95241 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMll'NO. <br /> . EH 13-24 IREV. /+r 6r <br /> EH:{•Ie i '-'i I <br /> it ' <br />