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APPLICATION FOR PEFUIT <br /> f SAN JOAQUIN COUNTY PUBLIC HE,r:LTH SERVICES <br /> C ENVIRONMENTAL HEALTH ilI V I S I ON <br /> I P O BOX 2009, S1'OCRTON, ;SCA 95201 b [fit <br /> E <br /> (209) 468-3447 ` <br /> _nAR PROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application 1s hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> apPlication is made in co®pliance'vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County <br /> ,,��'-Public Health Services. <br /> b Address —aL �ls Cityl Lot Site/Acreage.S2//-d- D-7- <br /> Owner's Name <br /> Address Phone <br /> Contractor Address License No. <br /> Phone <br /> T PE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR C7 OTHER p Monitoring well L� <br /> J� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r DISPOSAL FLD. PROP. LINE f <br /> FOUNDATION AGRICULTURE WELL' OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial r C Open Bottom ❑ Manteca pia, of Well Excavation Dia. of Well Casing <br /> U Domestic/Private .❑ Gravel Pack! 0 Tracy Type of Casing Specifications <br /> M Public `f"7 Other 0 Delta Depth of Grout Seal Type of Grout <br /> 0 irii0ation "Approrr, Depth C) Eastern Surface Seal Installed by <br /> Repair Work Done v Type of Pump , H.P. State Work Done _ NJ <br /> Will Destruction D Well Diameter , Sealing Material i Depth <br /> Depth f Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION' (No septic system permitted if public sewer is <br /> Installation will serve: Residence_. Commercial_ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms �J <br /> Character of soil to a depth of 3 feet: f Water table.depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of'Disposal <br /> Distance to nearest: Well Foundation Property Line i <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED 11 Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS 11 Depth I Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 /> 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 bedome subject to workman's compensation laws of California." Contractor's hiring or,sub-contracting signature <br /> certifies the following: "I certify that in the pbrformance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- <br /> tion laws of California." t <br /> The applicant mus call for all require inspections. Complete drawing on reverse side, <br /> Signed <br /> Tills: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date l <br /> Area <br /> Pit or Grout Inspection by f Data Final Inspection by !� Date Z <br /> Additional Comments; <br /> Applicant - Retura all Copies to: �-, <br /> P SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 <br /> FEE UNT DUE AMOUNT HEM:TTEO Cx A IVED EiY DATE PER N0. <br /> INFO CASH <br /> r 1. <br /> . FH"4.24(RFV.I/N 5) <br /> FH 3�•ie D-05, <br /> a! � i <br />