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F <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ' ENVIR_ONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009;j,,STOCBTON, CA 95201 <br /> PMT EXPIRES 1 YRM FROM DATE ISS19ED <br /> I (Complete in Triplicate) <br /> Application is hereby made,to San:Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Elan <br /> Joaquin County Public Health Services. <br /> Lot Size/Acreage r <br /> Job Address <br /> Phone <br /> 0 War's Name f Address <br /> o tractor dre <br /> n e No, honk"M <br /> ❑ WELL REPLACEMENT DESTRUCTION D Out Mo <br /> service Weil M <br /> TYPE OF WELL/PUMP: NEW WELL Monitoring Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> LL FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ O n.Bottom> ❑ Manteca.,. Dia. of WaEI Excavation Dia. of Well Casing <br /> u .,,.r.w ,_.- _ _.� .— —, <br /> omestic/Private C1 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 11 Public 1:1 Other .I fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. De h 1 Eastern �$Vice Seal Installed by { <br /> Repair Work Done U Type of Pum H.P. /� State Work Done <br /> Well Destruction ❑ Well Diamete 8ea11ttg Material i Depth <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No seplic'system permitted if public sewer is <br /> j available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other O <br /> Number of living units: Number of bedrooms ? ]� <br /> Character of soil to a depth of 3 feet: ) Water table depth <br /> SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT.L1Method of Disposal <br /> } <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/sire <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line ,\ <br /> 1 <br /> SEEPAGE PITS 11 Depth t Size Number i <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line e <br /> f ; <br /> E DISPOSAL PONDS ❑ i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin coy,ordinances, stale laws, and <br /> rules and regulations of the San Joaquin County o- <br /> Home owner or licensad 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 tolwoikman's compensa- <br /> tion laws of CslHornis." <br /> • ,' <br /> The applic st call or r wired inspections. Complete drawing on re r a side. <br /> Signed Title- i Date;_ <br /> FO EPARTMENT USE ONLY <br /> '77Date r ._q <br /> Z Area <br /> Application Accepted by _ <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 4 <br /> I Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Snvironmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE , AMOUNT REMITTED CAS RILCEIVED BY DATE PERMIT'NO. <br /> )NFO l <br /> ` r EH 1121 IREV.1/�4! �+ �� f� S <br /> �3 <br /> {les CH 14.26 <br />