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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> L-19" <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 made in compliance 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 AE CitySite/Acreage ` <br /> Owner's Nametf`diess � <br /> hone <br /> Contractor l��J� Addrs� >�'�� License No.�Phone 3 <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIFt+ OTHER 0 Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia, of Well Casing <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public C) Other C3 Delia Depth of Grout Seal Type of Grout <br /> ,Vrfioation Approx, Depth ❑ Eastern Su co Seal Installed by <br /> Repair Work Done Type of Pum -�yrp� � <br /> � � p ---/--t4[F_"� H.P.HP -- ._�. Sta[e.Work Dona <br /> Wall Destruction ❑ Well Diameter Sealing Material 4 Depth <br /> ! Depth. ' Filler Material ♦ Depth <br /> I TYPE OF,.SEPTICTWORK:—NEW INSTALLATION 11 REPAlRlADDITION Ll DESTRUCTION GI (No septic system permitted if public sewer is <br /> ' 1 available within 204 feet.) <br /> instaflalion"vVill ierve: 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. p Type/Mfg Capacity No. Compartments <br /> ' PKG. TREATMENT PLT, C'3 Method of Disposal <br /> 1 Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑d No. b Length of lines <br /> Total length/size <br /> I FILTER BED` r'�; 43 Distance.to-ynearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS I I Depth Size Number <br /> i SUMPS LI Distance to nearest: Well Foundation Pro <br /> ! DISPOSAL PONDS ❑ party Line <br /> x <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 persiorti"iniui fi marina►as ip become subject to workman's compen`aatiori law»of"California." Contracfrsr s tilling or sub-contracting 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 laws of California." <br /> The applicant o N r�-�;�io�nsCom�pleto d►awing onre�._ <br /> # Signed �� <br /> Title: Date: <br /> R DEPARTMENT USE ONLY <br /> t � t/f <br /> r Application Accepted by Date / Area <br /> Pit or Grout Inspection by Date d Final Inspectio by <br /> Datd� [. <br /> Additional Comments, .�. / r w r <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 2009, STOCKTON, CA 95201 <br /> FEE t CX f <br /> INFO �AIMOUNT OtJE AMOUNT R6MITTEO CASH RkEiVED BY DATE PERMI1'N0. <br /> iRkY <br /> . EH t3-24 . h f[i si (� ,� <br /> EH 3'2e 'V <br /> f <br />