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" APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI3 <br /> ENVIRONMENTAL HEALTH DIVISION ITE CE I <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 Q C T gPFMMIT EXPIRES 1 YEAR PROM DATE <br /> U\� I f..HEALTH <br /> (Complete in Triplicate) �'ERIYIT/SER,x/ ,..,_* <br /> iLL <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public alth Sery es. <br /> Job Address City t Size/Acreage <br /> Owner's Name Address Phone <br /> C ntr c Addre cense No 0Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Pf DESTRUCTION O Out of Service Well ❑ <br /> PUMP 1NSTALLATI01� SYSTEM REPAIR O OTHER O Monitoring Well C1 <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 /> n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> >#�_`mestic/Private <br /> O Gravel Pack O Tracy Type of Casing Specifications <br /> M Public 1'1 Other Delta Depth of Grout Seal Type of Grout <br /> G Irriostion Approx. Depth,_, stern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. ! State Work Don <br /> Well Destruction O Well Diameter Sealing Material R Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION Cl (No septic system permitted it public sewer is � <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other (� <br /> Number of living units: Number of bedrooms Jv <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.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> C`U <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> c, <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 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 h <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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signs ur <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 compensa- <br /> tion laws of California." <br /> The applies m at call fo all rad in ctidns. complete drawing on rev 'd 1 <br /> Sig d (1�JTitle: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection b <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 2009, STOCKTON, CA 95201 <br /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 13•74 111EV. sl ld/ <br /> EM;1•le <br />