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4 <br /> ~ F• � i <br /> 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 <br /> PERMIT EMIRES I YEAR_PROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is trade in conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address r CityLot Size/Acreage <br /> Owner's Name �����w Address Phone <br /> Contractor Gr V Address License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well Cl <br /> PUMP INSTALLATION 0 SYSTEM REPAIR OTHER p Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK �SEWER-LINES _ DISPOSAL FLD. PROP. LINE �. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �y <br /> n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing V <br /> EJ Domestic/Private Cf Gravel Pack 0 Tracy " Type-of-Casing Specifications <br /> M Public I'1 Other © Delta Depth of Grout Seal Type of Grout f <br /> 0 Irrigation Approx. Depih ❑ Eastern S irface SAW Installed by I <br /> Repair Work Done U Type of Pump . _Fi.P, State Work Done <br /> Well Destruction 0 Well Diameter _ Sealing maferiall Depth <br /> . ar Depth 7' Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION Ll DESTRUCTION CI INo septic system permitted if public sewer is <br /> available within 200 (eat.) <br /> Installation will server 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 Capacity "" _- No. Compartments <br /> PKG. TREATMENT PLT, Gl Method of Disposal <br /> Distance-to nearest: Well Foundation Property Line <br /> Ilk" <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED [_] Distance to nearest: Wall Foundation Propeny Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L'ri slance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS El ' <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 i <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 i <br /> employ any person in such manner as to become subject to workman's compensation laws of-California," Contractor's hiring of subcontracting signature <br /> certifies the following: "I certify that in the performance of Wi".work for which this permit is'issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant I/for all. aired i pections. Complete drawing on reverse side. <br /> Signed v Title: Crate: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area -212— <br /> Pit or Grout Inspection by Date Final Inspection by --4 Date <br /> L <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 2009, STOCKTON, CA 95201. <br /> FEE <br /> )NFO AMOUNT DUE AMOUNT REMITTED SK RECEIVED BY DATE PERMIT"N0. <br /> WEN-1' tR(V.riM sr s3� Cd <br />