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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 81 <br /> ENVIRONMENTAL HEALTH DIVISION MAY 9 rn <br /> ,P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL i`�Ir�t4LTH <br /> (209) 468-3447 PERWIT/SERVICES <br /> j I!MIT gaIRES 1 YEAR FROM DATE ISSUE. <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. This <br /> application is made in compliance Vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 6 <br /> �1 ® p r ad!: city Lot Size/Acreage <br /> Job Address - <br /> Owner's Name � i Address Phone <br /> ^�, <br /> Contractor `Address <br /> License No. 56� Phane <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ put of Service well Cl <br /> PUMP INSTALLATION <br /> SYSTEM REPAIRS OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION € AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INT DED USE TYPE OF WELL --J PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ gravel Pack- ❑ Tracy's 1 Type.of Casing Specifications <br /> [7 Public f-1 Other; ❑ Delta Depth of Grout Seal <br /> Type of Grout <br /> G Irrigation Approx.;Depth 0 Eastern Surface Saul Installed by <br /> Repair Work Done dY Type of Pump M.P! € State Work Done <br /> Well Destruction 0 Well Diameter seilin8 material i Depth <br /> Depth "� -t - Filler Material i Depth <br /> f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L-1 REPAIRIAOOITION lrl DESTRUCTION Cl septic system <br /> 200 feet.) if public sewer is , <br /> Installation will serve: Residence— Commercial___._ Other � <br /> Number of living units: Number-ol'bedrooms 1 <br /> Character of soil to a depth of 3 feet: 'r� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. El -1 <br /> Method of Disposal <br /> .Distance to nearest: Well Foundation Property Line u <br /> i <br /> z Total length/size <br /> LEACHING LINE Cl No. 8 Length of dines t. - g <br /> FILTER BED ❑ Distance to}nearest: Welt' 1 Foundation Property Lina <br /> SEEPAGE PITS I I Depth I Size Number <br /> SUMPS LI Distance to':nearest:! Well Foundation Property Line <br /> DISPOSAL PONDS ❑"""" ---\ <br /> ♦ W. - <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 taws, and <br /> n f h on Joaquin Count I .� <br /> rules end regulations s the S q Y <br /> Home owner or licensed agent's signature the following:`"I cenify`"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 worliman's`ompensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in theiperformance 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 applicant I or all required inspections. Complete drawing on reverse side. <br /> Signed X Title;��"— - - <br /> Date: g/ <br /> I <br /> i R DEPARTMENT USE ONLY p <br /> Application Accepted by9WDate ,0 Area <br /> Ar r 191 <br /> Pit or Grout Inspection by <br /> Data Final.Inspection by Date /9 <br /> Additional Comments: _ <br /> Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> i445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 <br /> FEE AMOUNT DUE 'AMOUNT irifilvlirTEO CASH HECErVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH 11.24MEV.r?KSid <br /> EN;{•1e <br /> I <br />