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f APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ' 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to > Joaquin County for a permit to construct and/or install the work <br /> herapplication is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules andein Regulations of Sans <br /> Joaquin County Public Health Services. <br /> Job Address S/ / <br /> City Lot Size/Acreage <br /> Owner's NameAdd <br /> Address G �'�e Phone <br /> Contractor C a. cl 1 �.lL rc Address cense No.� _ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REFSLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION L--' SYSTEM REPAIR L-1 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION""^"''— "AGRICULTURE"GVELL' OTHER WELL "="' "PITS/SIJMPS�� - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack B—'racy Type of Casing_ Specifications <br /> l"I Public 1-1 Other1l Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by ` <br /> Repair Work Done ❑ Type of Pump T�tr_ H,P. /r ' 11� <br /> State Work Done— .y W ; 2.7 � <br /> Well Destruction O Well Diameter " Sealing Material i Depth <br /> Depth ]tiller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION ( I DESTRUCTION I I Mo septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial— Other available within 200 feet.) I <br /> Number of living units: Number of bedrooms <br /> Character of soll to a depth of 3 feet: Water table depth i <br /> SEPTIC TANK. O Type/Mfg Capacity No. C r � <br /> PKG. TREATMENT PLT.Cl ALT <br /> Met I Y G v <br /> Distance to nearest: Well Foundation Property Li (\ i <br /> LEACHING LINE ❑ No. & Length of lines Total length/siz Q -+ <br /> FILTER BEDO Distance to nearest: Well Foundation Props r—u�n I Tu c <br /> HCl �4C �ERVICES <br /> IV15i0N <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPSL1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS" . ❑ � _—...—+;.^�- <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 person in such manner as to become subiect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> eartifies the following: "I certify that in the performance of of Califomthe work for which this permit is issued,I shall employ persons subject to workman's compensa <br /> tion lawn la." r <br /> The applicant <br /> call for ell required inspections. Complete drawing on reverse side. <br /> Signed X Title: DIY thy' Date: — ! _ <br /> FO RT DEPARTMENT USE ONLY <br /> Application Accepted by 1 Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date-6 <br /> Additional Comments: <br /> r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> - 445 N San Joaquin, P ox 2009, Stkn, CA 95201 <br /> FEEK i <br /> INF q AMOUNT DUE AMOUNT REMITTED p�/ ECEIVED BY DATE AERMITNO. <br /> . EH tY21 IREY.i i n sr �s <br /> fH 71.7e <br />