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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 95201 <br /> (209) 468-3447PEMIX EXPIRES I YEAR PROM DATE ISS "�• <br /> 4*0 <br /> (Complete in Triplicate) ` QPV <br /> P� 4 N <br /> Application is hereby made to Sam Joaquin County for a permit to construct and/or install the wo g'�it eQ01bed. This: <br /> application is made in corwlianee with San Joaquin County Ordinan o. 549 a 1662 and the Rules en'd �1 i rie� Lamin <br /> Joaquin County Public Health Services. � lCr 7 <br /> Job Address +t� J J�, 20�� Cit. Lot Size/Acreage <br /> Owner's Name Address Phone <br /> �cfor d ss <br /> ense No. Phone , <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 1-3 DESTRUCTION ❑ Out of Service Well D <br /> PUMP INSTALLATION SYSTEM REPAI OTHER © Monitoring Well L] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES KD POSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omastic/Private ❑ Gravel Pack L7 Tracy Type of Casing Specifications <br /> ❑ Public 1.1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> C3 Irsi ation Approxi P�Se&�'ling <br /> rf i a s�Depth� <br /> by ' <br /> RepairWorkDone Type of PumpState or Wine +� <br /> Well Destruction O Welt Diameter� ateri <br /> Depth ___,Y,30/ Filler Material i Depth �1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION JO REPAIR/ADDITION 0 DESTRUCTION G 1 N septic system permitted if public sewer is <br /> + available within 200 feet.l <br /> Installation will serve: Residence Commercial _ --Other---- <br /> Number <br /> -Other-_--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 No. Compartments , <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: WellFoundation Property Line <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number , <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> l 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 persons subject to workman's compensa. <br /> tion laws of California.' <br /> The applicant usl cal for II required i"pgations. Complete drawing on r arse side. / <br /> Sign Titl Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date !� Area <br /> Pit o►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 BOX 2008, STOCKTON, CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMIT-TED CASH RECEIVED by DATE PEAW7'NO, U <br /> EH 1 -24 r REV., 51 <br /> EH'.426 ` <br />