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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PE T EXPIRES I YEAR FROM DATE ISSUEP <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 made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of-San <br /> Joaquin County Public Health Service <br /> Job Address `- City Lot Size/Acreage <br /> Owner's Name r � Address Phone -?3--RI <br /> Contractor <br /> C Address <br /> _ _ � -Phone <br /> e License No �~ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ , Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ <br /> INTENDED USE­>'" ,. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications <br /> 1'I Public f-1 Other Cl Delta Depth of Grout Seat Type of Grout <br /> I I Ifrigation _Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done 13 Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth p� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i4—"—DESTRUCTION I I (No septic system permitted if public sewer is v` <br /> I L11-, available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: ___L Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK" 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.D Method of Disposal <br /> Distance to nearest: Well Foundation Property line <br /> � n <br /> LEACHING LINE & Nlo. & Length of lines r t--- -- .Total length/size <br /> FILTER BED 1:1Distance to nearest.. Well_r_jf!2ft_/ -c <br /> Foundation _ Property Line <br /> SEEPAGE PITS I 1 Depth Size a' "`�� Number <br /> SUMPS 4l—Distance to nowast: Well /yO Foundation Property Lino <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 t t <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 workmen'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 persons subject to workman's compensa- <br /> tion laws of California." F <br /> The applicant t I dor all required ' ' tion omplete drawing on reverse side. <br /> Signed TiNe: eC' Date: <br /> r <br /> rt t FO DEPARTMENT USE ONLY 1 <br /> Appt' ion Accepted by _ V Date " Area <br /> o► rout lns6ZtIon by? Date L,ZA Za ... Final Inspection by s Data q3 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUIPF DUE AMOUNTREMITTEDCK RECEIVED BY DATE PERMR'NO. <br />{ em 13-24 EH 14.14111EV.itrs) <4Q <br />