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y <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> rvo <br /> ENVIRONMENTAL-HEALTH DIVISION ' <br /> P O`BOS 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERNIT .EXPIRES 1 YSAR ROM DATE ISSUED <br /> (Complete in Triplicate) i <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 Health Services. <br /> Job Address 4:2- ,r !t�&n City Lot Size/Acreage <br /> Owner's Name <br /> Phone <br /> Address <br /> Contractor Address License No. Phone 1 <br /> TYPE OF WELL/PUM?: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER❑ f Monitoring Well {� <br /> R <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 r '+ <br /> C71 Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of-Casing Specifications <br /> M Public 1-1 Other ❑ Delta Depth.of Grout Seal Type of Grout <br /> Gf Irrigation __.—Approx, depth ❑ Eastern Surface Seal Installed by <br /> t I <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material is Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence-Commercial— Other <br /> Number of living units: _0- Number of bs S Y » <br /> Character of soil to a depth of 3 feet: SadroWater table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity____ Ze No. Compartments <br /> PKG. TREATMENT PLT. 0 � Method of Disposal <br /> Distance to nearest: Well onlL Foundation Property Line <br /> e <br /> LEACHING LINE Cl No. & Length of lines - - Total length/size <br /> FILTER BED [3 Distance to nearest: WeA - &4 Foundation Property Line <br /> SEEPAGE PITS [ I Depth ��''t`QSize Number - � <br /> I <br /> SUMPS Ll Distance to nearest: Well �Foundation Property Lina t l <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 , <br /> Home owner or licensed agent's signature certifies 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 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, I shall employ`� Y pe p y parsons subject to workman's compensa- <br /> tion lows of California." I <br /> The applicant must r sil quire psctions. Complete drawing on reverse side. j <br /> Signed Title: /'� G+ f/ <br /> Data: r <br /> �� FOt4kEPARTIMIENT USE ONLY } <br /> t <br /> Application Accepted by Date — �� Area <br /> Pit or Grout Inspection by Date Final Inspection by �jDate (/ l <br /> Additional Comments: { <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> _x 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 <br /> 'INFO AMOUNT DUE AMOUNT FIEMITTEO CASH RECEIVED BY DATE PERMITNO. <br /> • Ex,4. fRE1r. nS! [ OV / r ��� �/ �rP iLa;o <br />