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s APPLICATION FOR PERMIT <br /> SAN JOA U <br /> Q IN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR PRQX <br /> (Complete in Triplicate) <br /> Application in hermade <br /> a to $an Joaquin County for ri perrnit 'ta construct and/or install the work herein described. This <br /> application fe atade in co�liance 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 City Lot Size/Acreage <br /> wner's Name ��/ Address <br /> _. Phone <br /> kEy—oplt,r <br /> actor � AddressOF WELL/PUMP: License NO. Phone <br /> NEW WELL ❑ WELL REPLACE NT Q DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION SYSTEM €PAIR C1 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK L7 <br /> EWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION A ICULTUAE LL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR NSTRUCTION SPECIFICATIONS <br /> J Industrial ❑ Open Bottom ❑ Manteca i6, of Well Excavation <br /> U Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> C7 Tracy•-. Typ f Casing_ Specifications <br /> M Public I'3 Other 0 Delta Depth o in <br /> Seal <br /> Q litigation Type of Grout <br /> 0 `Approx. Depth n East Surface Seul tolled by <br /> Repair Work pone _U Type of Pump Fi p " <br /> Well Destruction State Work Done <br /> ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth' <br /> TYPE OF SEPTIC WORK; " NEW INSTALLATION L-1 REPAIR/ADDITION M DESTRUCTION INo so <br /> ic system permitted it Public sower is C <br /> vailabPl within 200 Permitted <br /> Installation will serve: Residence Commercial Other pr <br /> Number of living units: Number of bedrooms <br /> Character Of soil to a depth of 3 feet; <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg Capacity__,______—;_, No. Compartments <br /> PKG. TREATMENT PLT. Ll " <br /> Method of Disposal <br /> Distance to nearest: Well Foundation �______`� <br /> Property Line <br /> v <br /> LEACHING LINE 0 No. & Length of lines _ <br /> FILTER BED T4ral length/size <br /> n Distance to nearest: Well _ Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS � <br /> LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> 4 <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 I" <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 subcontracting signature <br /> certifies the following: "I certify that in the periormenca of the work for whith this permit is issued, I shall employ persons subject to workman's compensa• <br /> tion laws of ia." <br /> The applic t mus call for all re uired ins tions. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> FO&DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Data —A <br /> Area <br /> Pit or Grout Inspection by Date 1. <br /> �, Final Inspection by <br /> Additional Comments; / Z ��;, Date <br /> ca ICY <br /> Applicant !ea- Return all co to. ` <br /> p SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES / <br /> 445 N SAN JOAQUIN, P O BOX 2008, 9TOCKTON, CA 85201 �" �� <br /> FEE AMOUNT DUE AMOUNT AEMrTTEp CK <br /> INFO CASH RECEIVED BY DATE <br /> PERMIT"Nq, <br /> 13"24 tREV.rinyr "I <br />