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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH STRVIC$S <br /> ENVIRONMENTAL HEALTH DIVISION { A <br /> P O BOX 2009, STOCKTON, CA 95201 , <br /> (209) 468-3447 ` <br /> YEAR kROM DAIE JUSUED ' <br /> (Complete in Triplicate) t <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork 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 County Public Health ]Services. <br /> Job Address ��1) `x' L -- City � Lot Size/Acreage <br /> d-- -- <br /> I <br /> Owner's Name Address +�-� Phone <br /> Contracto c a,_ License 2- Phone <br /> 53-5 <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ out of Service Well Gl <br /> PUMP INSTALLATION E4-� SYSTEM REPAIR OTHER ❑ Monitoring Well [3 <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 /> Cl Ind Iel ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> omeatic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> R Public I:1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation Approx. Depth ❑ Eastern � � Surface Seal Installed by tl� <br /> Repair Work Done of Pumper H.P. i�"3r State Work Done 0 <br /> Well Destruction O Well Diameter Sealing Material i Depth f� G <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION ci lNo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence^ Commercial— Other ZZ <br /> Number of living units: Number of bedrooms <br /> Character of toll 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 neatest: Well Foundation Property Line ) <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Weil Foundation Property Line ^, <br /> SEEPAGE PITS 11 Depth Sire Number 1/ <br /> SUMPS LI Distance to nearest: 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 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 Celilornia," 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 persona subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mus sit for all regyirgd inspections. Complete drawing on reverse side, <br /> Signed X 4 Tide: Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date + v Area <br /> Pit or Grout Inspection by ter- Y ~Date Final Inspection by Date j <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 <br /> FEE K iT <br /> INFO AMOUNT DUE AMOUNT REM TTED CASH RECEIVED BY DATE PERMIT NO. f� <br /> . EH 43.24 IREV.i/"S) <br /> u.5.�� <br /> EH,�•Ie TIL <br />