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�— —� 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 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby roads 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 1862 and the Rules and RegulAtions of San <br /> Joaquin County1Public Health Services. IK, <br /> Job Address ��/�1)3 0 - �� \ A ' City L� � Lot Size/Acreage � _ <br /> Owner's Name ' ��C I)i AL Address Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well C1 <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well f� <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 /> [_l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatiofnti Lf Dia. of Well Casing _ <br /> [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ f-1 II Specifications <br /> Cl Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout <br /> IImUatwn — Approx, Depth I I Eastern Surface Soul Installed by //�� /� <br /> Repair Work Done Type of Pump H.P. State Work Done fw_ Cil �� <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth biller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public &awe( is <br /> available within 200 loot.) <br /> Installation will serve: Residence _ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soM 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 L1 No. 8 Length of lines _ Total length/size <br /> FILTER BED C) Distance to nearest: Well Foundation Propony Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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 /> 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 sub-contracting signature <br /> canities the It ing: ' nify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss <br /> tion Iowa of Cali;orn <br /> The applicant mus I for ui napectigps. tromplete drawing on reverse side. <br /> 400 Signedj _ — t, )JI-fl Title: Data: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dot, � ' � Z Area -�1+ <br /> Plt or Grout Inspection by / Date Final Inspection by Data <br /> Additional Comments: l) v <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box , Stkn, CA 95201 <br /> FEE INFO AMO�`U�NT DUE AMOUNT REMITTED Ce 03 <br /> CE VEjD by / DATE PERMIT NO. <br /> cH ii.y ucv.r,s er /.� L/ 1.lJ0 Lr� (lf� C Cjf�j Lf Z f �•, r' <br />