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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH <br /> ENVIRONMENTAL HEALTH DIVISI j <br /> 445 N SAN JOAQUIN, PHONE (209)4 a42 <br /> P 0 BOX 2009, STOCKTON, .CA 9 s <br /> PERMIT-EXPIRES ll FR DATE <br /> p �� LL (Complete in T.ri,plicite) <br /> Applicat oa is hereby made to Joaquin County for n permit to construct and/or t <br /> application s�a¢e a �1i&neviith San Joaquin County Ordinate No. 549 and 18 <br /> Joaquin C <br /> Job Add Ter/nme✓ One City /1 Lot Size/Acreage <br /> PE T V E5 d Phone <br /> Owner's Name r 0 Address a <br /> Contractor G r•� Address ?.0 f License No. SUJ - Phone9A'3 18 <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELLREPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well' ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑" ,O,THQER nitoring Well C]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 N <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.of Well Excavation Dia. of Well Casing <br /> IVDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ZA Specifications <br /> it Public 171 Other n Delta Depth of Grout Seal Type of Grout e <br /> CW <br /> I I Irrigation Approx. Depth X Eastern Surlace teal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. 'State Work Done <br /> Well Destruction O Well Diameter Sealing Naterial i Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I iNo seplic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of sod to a depth of 3 feet: Water table depth <br /> ` SEPTIC TANK. ❑ Type/Mfg Capacity <br /> Na. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: well., Foundation Property Lill <br /> LEACHING LINE ❑ No. 3 Length of lines Total length/size , <br /> FILTER BED © Distance to nearest: Well Foundation Property Una <br /> SEEPAGE PITS I I Depth Site Number <br /> SUMPS ❑ Distance to clearest: 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 laws, and <br /> rules and regulations of the Sen Joaquin County <br /> Horne 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 performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Catifomie." <br /> The applicant ceN for an ad inspections. Complete drawing on.reverse side. <br /> Signed X � ��� %UT.Gfi� Title: UtVldJ .S/ Date: <br /> f0• $��3 <br /> R USE ONLY.`. <br /> Application Accepted by Date J Area 3 _. <br /> Pit or Grout Inspection by Date T Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services a7r0/ ArSlo lj7ui <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> EM13.24 I11EV.I/ASA DO 7 C7 0 <br /> Ell 14.211 �' <br />