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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> i P O..BOX 2009, STOC%TON, CA 95201 <br /> 1 <br /> PERMIJ EgPIRES YE FR M DATE SII <br /> gg <br /> F (Complete in Triplicate) <br /> G Application is hereby made to San Joaquin County for a <br /> applicatioa is made in cCOVIlance with San Joaquin County ordinance rmit to nNo. 549struct aand o1862sand the eRules and vork eRegulations of Sanl.n described. s <br /> Joaquin County Public Health Services. <br /> Job Address <br /> City Lot Size/Acreage <br /> Owner's Name Address Address <br /> Phone ��•�� <br /> Contractor f <br /> Address <br /> i'O ' icense No. Phone <br /> TYPE OF WELL UM NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION C7 Out of Service well a <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 0 Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK � ' <br /> 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 /> ❑ Industrial O Open Bottom O Manteca Dia. of Wel! Excavationy <br /> 0(Domestic/Private Cl Gravel Pack n Tracy Type of Casing_ Dia. of Well Casing <br /> I'I Public [:7 Other n Delta Specifications <br /> Depth of Grout Seal ,Type of Grout <br /> I I Irrigationx Aplxox. pa th l I Eastern Surface Seal installed by <br /> Repair Work Done IX, Type of Pump H.p. L �d�im4 q <br /> Well Destruction Stat Work Don <br /> 0 Well Diameter Sealing;Material i Depth � <br /> Depth Filler;XLterial a Depth OA <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.I. REPAIR/ADDITION I 1 DESTRUCTION I I (No septic systern permitted if public sewer is <br /> Installation will serve: Residence_ Commercial� Other available within 200 teat.l <br /> Number of living units; Number of bedrooms <br /> Character of toll to a depth of 3 feet: 1 <br /> SEPTIC TANK. Water table depth <br /> ❑ Type/Mfg -x Capacity No. Compa"yt <br /> PKG. TREATMENT PLT.❑ 1 <br /> r r Method of�� ; <br /> Dance to nearest: Well + - ..Foundation—�^ <br /> • Property tine A <br /> LEACHING LINE 0 No. 8 Length of lines ffu-T 0 1993 <br /> FILTER BEDTotal length/size OUNTY <br /> ❑ pittance to nearest: Wall Foundation _ Propel 1.41BLIC HEALTH SES'- ° ti <br /> NVIRUMUTREHEAL1h u,vwiQN <br /> SEEPAGE PITS 11 Depth Size <br />.*_ SUMPS Number <br /> LI Distance to nearest:._ Well Foundation ' <br /> DISPOSAL PONDS ❑ - Praperty_L-ine_ <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 <br /> employ any person in such manner as to become subject to workman's compensation permit is issued, I shall not <br /> certifies the following: pensetion Iavvs o}California."Contractor's hiring or sub-contracting signature r <br /> g: "!certify that in tfla 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 ust call for all uir nspgctions. Complete drawing on revWe si e. <br /> Signed Title: <br /> Date: <br /> �AWF DEPAENT LI ONLY <br /> Application Accepted by Dat* <br /> tea�2f� <br /> Pit or Grout Inspection by .1. . -9 k= <br /> Final pate Inspect <br /> , ion by <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 0 Bos 2009, Stkn, QA 95201 <br /> FEE AMOUNT OUE AMOUNT REMITTED CK <br /> INFO anl CAS RECEIVED BY DATE PERM17'NO. <br />. EK M24(REV.I/old fJD I + I <br /> FH 14•76 <br />