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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT MIRES I YEAR 9BQX RATE ISSUED <br /> (Complete in 'Triplicate) <br /> Application is heresy made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application 1e made in coupliance.with San Joaquin County Ordinance No. .549 and 1862 and the Rules and Regulations of than <br /> Joaquin County Public Health vic a. <br /> Job AddZ!;�3 �2CCity Lot Size/Acreage <br /> Owner's Name Address T,_, _ Phone <br /> a <br /> Contra ress 2,0�F,/LJ t�L Eense N Pho <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ ? <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Mlonitoring 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 /> C71 Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> A Public la Other 0 Delta Depth of Grout Seal Type of Grout <br /> ❑ hfigation —.Approx. Depth ❑ Eastern Surface Soul Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done 0 <br /> Well Destruction ❑ Well Diameter} Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIRIADDITION CT DESTRUCTION INo septic system permitted it public sewer is r-r <br /> available within 200 feet.) <br /> instailation 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 Capacity �a No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal <br /> Distance to nearest: kWeII40 _ Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to i nearest: Well Foundation Property Line <br /> SEEPAGE PITS IJ Depth Sias Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I, <br /> I hereby comity 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 conifies 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 /> sonifies 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." <br /> i <br /> The appGcan r al squired inspac ns. Complete drawingrse side. <br /> Signe .Titl Date: <br /> 0 P TMENT USE ONLY <br /> Application Accepted by Date <br /> Area l <br /> Pit or Grout Inspection by Date Final Inspection by Dats/� �+ <br /> 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 0 BOX 2009, STOCKTON, CA 95201 <br /> K f <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED jCASH RECEIVED BY r DATE PERMIT'NO. <br /> . EN 1,41, rREV.IinSs ! !• v V OIJ S� S r► \ f L 4 - a -p�U L <br /> EN^426 <br /> p7qi C.3 <br />