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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE � .a 'l ' <br /> ENVIRONMENTAL HEALTH DIVISIONS <br /> P O BOX 2009, STOCKTON, CA 95201 DEC 1 8 9Q90 <br /> (209) 468-3447 <br /> - YEAR rROX PATE laolpV1RONMENTAL HEALTH <br /> (COMPlete in Triplicate) . PERMIT/SERVICES <br /> Application is hereby made,110 San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application 18 made in coatpliance with Ban Joaquin County Ordinance No. 549 and 2862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> al, <br /> Job Address 'h �LJI <br /> —r � II I •,-.- _ City Lot Size/Acreage <br /> Owner's Name Address �� -- ., Phone <br /> Contractor ` ddressrp( l <br /> License hfo. _.Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ P <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 0 Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE s <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS , <br /> INTENDED USE TYPE:I OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ZAQomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> R PublicI'1 Olher ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irrigation Approx. Depth t 0 Eastern Surface Seal Installed by <br /> �, <br /> Repair Work Dons Type of Pump H.P. <br /> Well Destruction ❑ Wel! DiameterIV <br /> Seal Materiali Depth State Work Done T <br /> Depth filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION MDESTRUCTION CI (No septics stem <br /> , y permitted if public sewer is <br /> Installation will serve: Residency Commercial —-'Other <br /> available within 200 feet.) Ci <br /> jP - •:" . <br /> Number of living units: Number of bedrooma'�---- <br /> Character of*oil to a depth of 3 feet: <br /> Water table depth r� <br /> SEPTIC TANK 0 Type/Mfg Capacity Not Compartments <br /> PKG. TREATMENT PLT. G1 Method of Disposal <br /> Dista' . <br /> Distance to nearest: Welt Foundation Property ply PertY Lina <br /> LEACHING LINE C1 No. & Length of lines { yTola!_length'/size <br /> FILTER BED [l Distance to nearest: Well Foundation Property Linew .> _ <br /> SEEPAGE PITS 1 1 Depth. Size Number ' <br /> SUMPS -. _ <br /> GI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS.' O <br /> I hereby comity 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 cemifies 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 es to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I comity thatin the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa• <br /> tion laws of California." II�' <br /> The applicant m all or all require inspections. Complete drawing on reverse side. <br /> Signed '' € Title: <br /> Date: <br /> F DEPARTMENT USE ONLY <br /> pplicatkon-Accep by-" <br /> Atv Data Area T <br /> Pit or Grout Inspection by Date Final Inspection.bydata <br /> Additional Comments: �� I <br /> Applicant - Return all capieai1to: 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 INFO AMOUNT DUI AMOUNT REMITTED CK CASH RECEIVED 9Y DATE PERMIT.NO. <br /> EH I! <br />+ Ew 13. TREY.i i n Si <br /> II , <br />