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APPLICATION FOR PERMIT <br /> 4 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL REALTH DIVISION <br /> ! P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> ATE i <br /> WM <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 oompliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Ser'ves. <br /> Job AddressRCity Lot Size/Acreage �AC.YL <br /> Owner's Name �. Address Phone <br /> I <br /> Conlractor Address f�M __ License No. Phone <br /> i TYPE OF WELL UMP: NEW WELL 8— WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well <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 .01 <br /> k <br /> 0 Industrial ❑ Open Bottom 13 Manteca Dis, of Well Excaa(pn Dia. of Well Casing <br /> �U/Domestic/Private eGravel Pack W"Tracy Type of Casing / Specifications <br /> I +L1 Public is glpersr7f I ❑ Delta Depth of Grout Seal --- Type of Grout <br /> f 7 7rtwit E'u <br /> GI Irrigation3 a Approxi. Depth Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Oona <br /> Welt Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth `4 22-0 Filler Materiel i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION fl REPAIRIADOITION ❑ DESTRUCTION CI (No septic system permitted if public sewer is <br /> .-cam I 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 r Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 V,N. L Method of Disposal <br /> Distance,Jo nearest: Well Foundation Property Line <br /> 4Ff LEACHING LINE A ''Cl No. III Length of lines Total length/size <br /> FILTER BED °n Distance;to nearest: Well Foundation Property Line <br /> {SEEPAGE PITS 11 depth i f Size r Number <br /> SUMPS Cl 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,` r <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 .F <br /> employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or subcontracting 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 compensa- <br /> tion laws of California." I <br /> The app must call for eq d inspgstions:.Complete drawing onnse side. o <br /> Signed Title: 1. J 41 i/r !) _..--.-- Date: i <br /> FOfFWET4ZLRTMENT USE ONLY <br /> f Application Accepted by ! j Date Area <br /> t it ti <br /> Pi r Grout I coon by ate a SID Final Inspection by ( Date <br /> r 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 2000, STOCKTON, CA 95201 <br /> EEE AMOUNT DUE1 AMOUNT REMITTED CK 11 CASH RECEIVED BY DATE PERMIT NO. <br /> INFO p� <br /> s EH 13-24 IREV.1/n 51 f/ �� �' ���a t� <br />