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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> ?' , <br /> P O BOX 2009, STOCgTON, CA 95201 - Wv <br /> RERMIT E%PIRES 1 ITAR FROM DATE ISSUED �D r <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in caropliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address C'itty� Lot Size/Acreage <br /> Owner's NameAddress � <br /> fC/[_!��/ /�L7 Phone <br /> Contractor Address License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well �} <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ Monitoring Well ❑ <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C:l Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> i"1 Public f-I Other F1 Delta Depth of Grout Seal Type of Grout f� <br /> I i Irrigation —Approx. Depth l I Eastern Surface Seal Installed by 1 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction D Well Diameter Sealing Material i Depth j <br /> Depth Filler Material & Depth l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION No septic system permitted it public sewer is <br /> avail$ble within 200 feet.) <br /> Installation will serve; Resi lance— 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. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0Method of Disposal <br /> Distance to nearest: Well Foundation Property Line P <br /> LEACHING LINE ❑ No. & Length of lines Total length/size P <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the 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 mutSr all od i ions. pomplete drawing on reverse side, <br /> \ Signed <br /> Title: Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Z J <br /> Sib )PP— Date Area <br /> i <br /> Pit or Grout inspection by Data Final Inspection by Date <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, P O Box 2005, Stkn, CA 95201 <br /> FEE AMOUNT DUEf�A;M�OUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. <br /> INFO /7 CASH <br />. FN 13.24 IRIV.1/"d C. , C:� 0`2 <br />