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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 06 <br /> ENVIRONMiENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES I XF <br /> 4H FROM DATE ISSUED <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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. A G <br /> Job Address Z fX� Lt7 City 44aA - Lot Size/Acreage <br /> ��' <br /> /�It.G� SQF Phone <br /> Owner's Name � - Address <br /> Contractor f Address 7� License No. d___7? — <br /> 2 <br /> ' Phont33 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION D Out of Service Well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR El OTHER O <br /> Monitoring Well � <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 /> D Industrial ❑ Open Bottom © Manteca Die. of Well Excavation Oia. of Well Casing <br /> ,Domestic/Private Gravel Pack ` 0 Tracy Type of Casing_. 1097'L° Specifications. <br /> f'1 Public 1-1 Other %'gt 1Acn f-1 Delta Depth of Grout Seal 0 Type of Grout CA C-`Z _ Q <br /> i I litigation -Q-Approx. Depth I 1 Eastern Surface Seal Installed by d "� <br /> Repair Work Done 0 Type of Pump H.P. S Stat4 Work Done_ VAC- <br /> Well Destruction 0 Well Diameter l Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I f REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will some: 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. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest. Well Foundation Property Line <br /> LEACHING LINE Cl No. a Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation ,Property Lina <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 /> Homs owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for virftich 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 sonify 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 must all f elf required inspections. Complete drawing on reverse side. <br /> Sigma Title: Date: <br /> FO DEPARTMENT USE ONLY 1 <br /> Application Accepted by Date <br /> Pit Grou apection by <br /> Date - Final Inspection by ` Data <br /> Addkional Comments: <br /> Applicant - Return all copies to: San Joaquin County public Health ervices <br /> Environmental Health Permit/Services <br /> 445• N San Joaquin, P 0 Box 2009, Stkn, CA 9520). <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED SY DATE PERMIT*NO. <br /> INFO <br /> . EM 1344 ItIEV.t ins) vy" - <br /> EH 1441 �/ <br />