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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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 coMliance 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 City /' �ot Size/Acreage <br /> � <br /> Owner's Name IAJrAddress 0_3 � l Phone <br /> • <br /> Contractor I4 Address ' Zense N <br /> Phon <br /> 147A <br /> TYPE OF WELL/PUMP: N EW WELL WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION O, SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> d.:....� +.� FOUNDATIONr= d AGRICULTURE WEL rOTHER.WELL. .PITSLSUMP_S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> C) Industrial 11Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> t"omesticlPrivate tiglilavel Pack ❑ Tracy Type of Casing_ Specifications <br /> V1 Public 1-101 f-1 Delta Depth of Grout Seal Type of Grout <br /> t I irrigation ,7t'��prox. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth O <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewef is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> t Character of goo to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity—.. NoRtffP r n <br /> PKG. TREATMENT PLT. ❑ M"C!Li <br /> Distance to nearest: Well Foundation Property ki <br /> LEACHING LINE Cl No. 6 Length of lines n Total le gt AN J DEALTH SERVICES <br /> to nearest. Wail Foundation F <br /> FILTER BED D Distance `�` -�NV��ENAL HEALTH DIVISION <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ._ ❑ - . I — <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 /> Horne 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> I The applicant myst call for all re4uirad inspection . Complete drawingon r verse side. <br /> r C. <br /> Signed Title: Date: �� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byIV Date T Area <br /> Pit or Grout Inspection by /r/l Date Final Inspection by Date '3 7� <br /> Additional Comments: J U e <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N 3 quin, P 0 Boz 2009, Stkn, CA 95201 <br /> FEEAMOUNT DUE MOUNT REM RECEIVED BY DATE PERMIT�NO. <br /> INFO CASH <br /> + EH 13.24IREV.I/as) vies <br /> EH 14.28 V ff <br />