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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ��� <br /> ENVIRONMENTAL HEALTH DIVISION L"Imp t n 2 19.99 <br /> P O BOX 2009, STOCKTON, CA 95201 f�j ,,P, rA <br /> (209) 468-3447 '' I!)r VICES rH <br /> PENIT .MIRES 3. YEAR & LSSUBD <br /> I (Complete in Triplicate) <br /> Application is hereby made 'to San Joaquin County for a permit to construct and/or install the work herein described. Thia <br /> application is Stade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> rr <br /> Job Address ,3 o7 i ` { City Lot Site/Acreage <br /> Address _�c '�~�'p`��- - --— Phone <br /> Owner's Name �m � -- -. <br /> r G�PP c�0License No. ^ � Phone <br /> • Conttacto �- Address <br /> TYPE OF WELL/PUMP: NEW WELL 0WELL REPLACEMENT ❑ DESTRUCTION C} Out of Service Well Cl <br /> PUMP INSTALLATION lZt-� SYSTEM REPAIR OTHER C3 Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK -= SEWER LINES DISPOSAL FLD. PROP, LINE r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM.AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �estic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications <br /> ❑ Public I:1 Other '❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Iftigaiion Approx. Depth ❑ Eastern Su+rfeco Seal Installed by 4 <br /> Repair Work Done L5� Type of.Pump 45f! <br /> Repair State Work Dona (� ; <br /> Well Destruction 0 Well OiaMetef,l Sealing Material i Depth CfV <br /> Depth — _Filler Material & Depth t3 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADD TII ON M DESTRUCTION G (No septic system permitted if public sewer is <br /> .� . available within 200 feet.) <br /> Installation will serve:, Residence ._ Commercial Other c <br /> Number of living units: Number of bedrooms err <br /> Character of soil to a depth of 3 feet: + Water table depth <br /> SEPTIC TANK: ❑ Type/Mfg I Capacity No. Compartments <br /> �.PKG..TREATMENT PLT.0 I Method of Disposal <br /> Distance to:nearest: Well Foundation Property Line <br /> LEACHING LINE L1 No. & Length of lines Total length/size Q <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth L� Size Number <br /> SUMPS Ul Distance t(T?Mearssu Well Foundation Property Line <br /> DISPOSAL PONDS ❑ II <br /> I hereby certify that I have prepared this aipplication 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 eignatureleenifies 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 of sub-contracting signature <br /> certifies the fallowing: "I certify that in the 4performance 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 applicant must cal r all req i d inspections. Complete drawing onr arse side <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by j Date hzhr <br /> 14 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 AMOUNT DUE AMOUNT AEMITTEDCKS-CASH RECEEVED BY DATE PERM17'N0. <br /> INFO ,,�!� <br /> + E„13.741REV.i/AV f" tT� 17�tf� 7n/I <br /> Lf Jz- /22-� <br /> E►t <br />