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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 9520 . <br /> (209) 468-3447 <br /> PERMIT MEMO 1 YEAR PROIL DATE 159= <br /> (Complete in Triplicate) <br /> Application is hereby made;to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health ervices. <br /> 5 T� <br /> Job Address City Lot Size/Acreage <br /> Owner's Name + '' Address �l' Phone <br /> Contractor Pi <br /> x 'Addiess _ License N��._._Phone <br /> TYPE OF W LL/PUM : NEW WELL.❑ WELL REPLAC MENT C1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well a <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 /> ri Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation pia. of Well Casing <br /> U Domestic/Private Ll Gravel Pack 0 Tracy Type of Caning Specifications <br /> — <br /> M Public 1-1 Other CJ Delta Depth of Grout Seal Type of Grout <br /> G Irrigation Approx. Depth ❑ Eastern Surface Sedl Installed by <br /> Repair Work Done U Type of Pump _ _....H.P. State Work Done _ <br /> Weil Destruction ❑ Well Diameter Sealing Material 6 Depth <br /> Depth' Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR./ADDITION 0 DESTRUCTIONe (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: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg a it No. Compartments <br /> PKG. TREATMENT PLT.0 � GZ� Method_ of Disposal <br /> Distance to rTearest: Well Foundation �Property Lihe - <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER 13ED n Distance to nearest: Well Foundation Properly Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line ? <br /> DISPOSAL PONOS O <br /> I hereby certify that f 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all requi eivi tions. mplet d awing on rover" side. / p <br /> Title: ----— Date: <br /> FOR DEPARTMENT USE ONLY <br /> / <br /> Application Accepted by :_Z: _ ., _.,.,._.,. Date � r (p C, Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 SOX 2008, STOCKTON, CA 05201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED Ck <br /> CASH ECEIVED BY DATE PERMIT'NO. <br /> EH 13.24OIEV.+iw51 <br /> CH 7�•2a (J pf <br />