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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 <br /> P IT MIRES 1 YEAR FROM PATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby mage 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 le62 and the <br /> Joaquin County Public Health Services. .Rules and Regulations of San <br /> Job Address r City5�1. Lot Size/Acreage <br /> Owner's Name _rp1,a1�. V�� Address SP,'V)q (5 Phone <br /> Contractor Address S Licth No; Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I`I DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER-❑ Monitoring Well C7 <br /> 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "p1SPOSAL-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 /> CJ Domestic/Private Cl Gravel Pack 0 Tracy Type_af._Casing . _. Specifications <br /> ❑ Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> G Irrigation —Approx, Depth ❑ Eastern Surface Soul Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work pone= ^ . <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth y <br /> Depth Filler Material i Depth �,� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑-REPAIR/ADDITION ( <br /> STRUCTION G iNo septic system permitted if public sewer is "�I <br /> r i available within 200 feet.1 \„ <br /> E Installation will serve: Residence �mmerciaf—:, 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 <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Method_of.Disposal- _ <br /> Distance to nearest: Well Foundation Property Line <br /> F <br /> 1 <br /> LEACHING LINE Cho. b Length of tines © P Total length/size r <br /> FILTER BED 1-1 Distance to nearest: Well Foundation <br /> Progeny Line <br /> SEEPAGE PITS I tL�pth Size <br /> /�Number <br /> SUMPS <br /> LI Distance to nearest: well Foundation_,L_ � Property Line _5- <br /> DISPOSAL PONDS ❑ <br /> I hereby cenify 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'CaOornia." 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 shalSm,ploy_persons_subject-to workman_s_compenss- <br /> tion laws of Catifornla." <br /> The app' st c II or requr d in ctio mplete drawing on r verse side <br /> Sign !l - ; .. F <br /> Tide: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by <br /> A <br /> Date <br /> ,_._r Area <br /> _ <br /> Pit or Grout Inspection by Date _ Final Inspection by <br /> Date <br /> Additional Comments: <br /> Applicant - Return all copies to: BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` <br /> ——ENVIRONMENTAL-HEALTH-DIVISION-PER111I•T/SERVICBS ..T- <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCXTON, CA 95201 �. <br /> FEE AMOUNT DUE , AMOUNT REMITTED CK <br /> INFO CASH RECEIVED 8Y DATE PERMIT'NO. <br /> . EH A-20 <br /> ItRei ffD of1_.7f3 <br />