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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 I Y 4B-FROM DATE ISSUM <br /> (Complete in Triplicate) <br /> Application is hereby made-toSan 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 BeguLtione San <br /> application <br /> Joaquin County Public Health Service �.o�ar � ��t � <br /> Job Address Cit Lot Size/Acreage Ot"A"r <br /> Owner's Name Address Phone <br /> --fAp <br /> Contrac dress icense No. hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION LI Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 /> * Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> i'7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 1'1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation --__Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. Statq Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth / s <br /> Depth Tiller Material A Depth W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: R ' ence Commercial_ ther <br /> Number of living units: Number of ms i + <br /> Character of SON to a th of 3 feet: Water table depth 4 <br /> �j , <br /> SEPTIC TANK. Q¢ Typs/Mfg Capacity No. Compartments Ig <br /> PKG. TREATMENT PLT.O ! 1. Method of-�Dispoiai <br /> Distance to nearest: Well A400 Foundation A� Property Line C _ <br /> LEACHING LINE No. & Length of lines R Total lengtli.41ze K <br /> FILTER BED ❑ Distance to nearest: Well C.0 Foundation ID Property Line S Q <br /> SEEPAGE PITS Depth Size Number i <br /> SUMPS LI Distance to nearest: Well i� Foundation Property Line 7 5 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the workwill be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Cout,ty I . <br /> Noma 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 /> certifies the following:"I certify 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 st call IOV I reauired inspections. Complete drawing on reverse i <br /> SignedTitle: r Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data� Area -- <br /> 4�PPor Grout inspection by� Date��� Final Inspection by � Date <br /> Additional Commants: <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 2009, Stkn, CA 95201 <br /> K <br /> AMOUNT DUE AMOUNT REMITTED CASH K I RECEIVED BY DATE PERMIT'NO, <br /> . Ers,1].IREV.t,rrsi1 r `-i °r ( y °'� l�sc7� k b�7-1(01 3 q3-69q <br /> EM,..�a <br />