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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) 468-3447 /Jpff� <br /> PERMIT E%PIRES ] YEAR FROM DATE ISSWR <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 ccatpliance vith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> J in County Public Health Services. <br /> Job Address (V Ie. City Lot Size/Acreage <br /> Owner's Name `� )address � -Su e� Phone <br /> Contractor Address License No. Phone CS` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 out of Service Hell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DIST 0 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TY WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0-Tracy Type of Casing Specifications <br /> M Public is Other ❑ Deltaaeplh of Grout Seal Type of Grout <br /> CJ Irrigation —Approx. Depth ❑ Eastern 5uriice_5eal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Materiae' & Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION I INo septic system permitted if public sewer is <br /> vailable within 200 teat.! <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 0 Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line V <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> 1 hereby certify that I have prepared this application and that the work wiSl 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 thatinthe 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 subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa• <br /> tion taws of California." <br /> The applicant ust call for all req inspections. Complete drawing on reverse side. <br /> Signed Title: Date: _ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date `t Area <br /> 1 <br /> Pit or Grout Inspection by Date Final Inspection by J Date 691 <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 O BOX 09, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE A OUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> CASH <br /> EV ��Ir <br /> EMA-20 �' 10 <br /> S pEH s <br /> , <br />