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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PEli IT EXP-I_RES 1 YEAR RQ V DATE JSSUM <br /> (Complete in Triplicate) I <br /> Application is hereby trade to San Joaquin County for a permit to construct and/or install the work hereinldescribed. This <br /> application is made in cemyliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San <br /> Joaquin County Public Health Services."' <br /> Job Address .��f [_ 1'' City Lot Size/Acreage e <br /> Owner's Name LL!4-4-�� Address �r ` Phone <br /> Contract �`�� J Address f��/� License No� Pho // <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTIONOut of Service Well LlPUMP INSTALLATION 0� SE <br /> �. YSTEMWRPAIfl 0 Y-� OTHER Q Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK __ __.__ _____ SEWER LINES DISPOSAL FLD. PIROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> G Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> t <br /> M Public 1-1 Other p Delta Depth of Grout Seal Type of Grout <br /> G Irfivalion _.Approx. Depth C3 Eastern Surface Seal Installed by = <br /> Repair Work Done U T t <br /> p Type of PumpI +yH.P. State Work Done <br /> Well Destruction / Wail Diameter Sealing Material & Depth <br /> ` Depth Filler Material f1: Depth >. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION Cl (No septic system permitted it public sewer is <br /> available within 20011ee1.1 <br /> Installation will serve: Residence—1 Commercial— Other t ` <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:' -,�f Waterlatble depth <br /> SEPTIC TANK 0 Type/Mf <br /> p ____ Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 #. Method of Disposal <br /> Distance to nearest: Well Foundation Property Line I <br /> LEACHING LINE Ll No. & Lengthof lines Total length/size <br /> FILTER BED lTl Distance to n areal: Well Foundation Property Lina � <br /> SEEPAGE PITS 11 Depth { Size Number <br /> SUMPS CI Distance ib nearest: Well Foundation— Property Line <br /> DISPOSAL PONDS 0 1 4 <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, t shall not <br /> employ any person in such manner as wbecome 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 persona dubject to workman's compensa- <br /> tion laws of California." 1 <br /> The app lica , m st tar at eq"inspections. Complete drawing on (averse side. �- <br /> Signed ` Title: Date: <br /> H_Q ARTMENT,USE ONLY t <br /> Application Accepted by Date e�. ! Arab J _ <br /> Pit or Grout Inspection by Date Final Inspection by Data/- <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 O BOX 2009, STOCKTON. CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT rREMIT'TED CASH RECEIVED BY .DATE PERMIT NO. <br /> EH 17.24 IREV.I/n 5) /I']E . '1 `4� OM9 <br /> H 14-2e �/ [iv <br /> i <br />