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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCSTON, CA 95201 <br /> (209) 468-3447 <br /> PMIT EXPIRES 1 YEAR PM DATE... <br /> (Complete in Triplicate) <br /> Application In hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is rade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules Lad Regulations of 'San <br /> Joaquin County Public Health Services. <br /> Job Address _ R, City � t=om Lot Size/Acreage <br /> Owner's NameIV)tVidAddress ' �� Phone <br /> Contractor r Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service bell ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR O OTHER 0 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 /> [1 Industrial 0 Open Bottom ElManteca Dia, of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> Z `Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> a Ifrrgation —.Approx. Depth ❑ Eastern Surface Seal Installed by 1 <br /> Repair Work Done U Type of Pump H.P. - - State Work Done 11`11 <br /> Well Destruction D Well Diameter Sealing Material a Depth <br /> Depth -Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D - REPAIRlADOITION L1 DESTRUCTIONA (-No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_,.,, Othef <br /> Number of living units: Number of bedrooms ` <br /> i Character of&oil to a depth of 3 feet: V Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity f No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> G <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> I <br /> k SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 <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 <br /> employ any person in such manner as to become subject to workman'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, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call fora re aired i s tion . Complete drawing on reverse side. c ' <br /> Signed Title: - Data: " �—G d — <br /> k���F RDERTMENT U5E ONLY <br /> r` 4 <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: f y A <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES KAI,` <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO, <br /> i N F O Cd[�A/S M <br /> . FH t3.211IIEV.iitSl %G,4 �� "/ "� /C!JJ� ✓�t� / f/r(V^!r� ��//��`•' V <br /> EH i4•20 <br />