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APPLICATION FOR PERMIT S , <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION No <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> /C-k:NA <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUEDL <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 to made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services{ JJ s � <br /> city° t Size/Acreage 1 �Kjob Address <br /> Address I - Phone <br /> Owner's No <br /> ctor <br /> ,C Address License No. Phone <br /> WPUMP: NEW WELL ❑ ' WELL REPLACEMENT C7 DESTRUCTION ❑ Out Mo <br /> Service Well 0 <br /> LTYPE0_F _ELL/ <br /> Monitoring Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR L7 OTHER ❑ <br /> DISTANCE TO-NEAREST: SEPTICTANK ` <br /> ER LINES--DISPOSAL FLD- PROP. LINE <br /> FOUNDATION AGRI URE WELL OTHER WELL PITS/SUMPS ._ <br /> INTENDED USE TYPE OF WEL PROBLEM AREA CON ION SPECIFICATIONS Dia. of Well Casing \ i <br /> n Industrial ❑ Open Botto ❑ Manteca of Well Excav <br /> Specifications <br /> [-I DomesticlPrivate ❑ Gravel P k ❑ Tracy Type of Casing-- Type of Grout <br /> 1"1 Public EI Other n Depth of Grout Seal <br /> I I Irrigation A prox. Dept I Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type o - H.P.- State Work Done_ <br /> Sealing Material A Depth <br /> Well Destruction D Wall Diameter !'filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I 1 DESTRUCTIO INN�iWailabpe{wllhsn 200 Iremetl'ed it public sewer is <br /> Installation will serve: Residence—j Commercial Other <br /> Number of living units: Number of bedrooms <br /> A .Char'actnr of soq to'a depth of,l feet:' N. Water table depth <br /> SEPTIC TANK O Type/Mfg, Capacity No. Compartments <br /> i PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> l - - = - •-w �7otal <br /> LEACHING LINE ❑ No. 8 Length of-linea•--- --'�" ..length I size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> t SUMPS LI Distance to nearest: <br /> Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 lays, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I sha11 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 cenify that in the performance of the work for which this`permit is issued, I&hall employ persons subject to workman's compensa• <br /> tion laws of Collfornis." <br /> The applicant must tali for all required in no. plate drawing on reverse side. <br /> X\SIgrood _- <br /> Title: C& Date: <br /> r F DEPARTMENT USE ONLY <br /> Date - Area 72- <br /> Application Accepted by ?� <br /> ]y <br /> I Pk or Grout Inspection by Data <br /> Final lnapection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services V, <br /> 445 H San Joaquin, P 0 Sox 2009, Stkn, CA 95201 <br /> / FEE AMOUNT DUE AMOUNX REMITTED � - RECEIVED 9Y DATE PERMIT'NO. <br /> INFO 7 <br /> ..'.EN 13.24(01V..r K eY ©� <br /> EM t�•36 <br />