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- <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONKENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PEMIT EXPIRES 1 X90 FROM DATE- ISSUED <br /> (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 San <br /> Joaquin County Public health Services. <br /> !1��Job Address City Lot Size/Acreage <br /> Owner's Name Address Phone <br /> Contract Addre /� 1� License NomPhon �T <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well Gl <br /> PUMP INSTALLATION It> SYSTEM REPAIR OTHER ❑ Monitoring Well n <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 /> 0In�dustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i.Y6omestic/Private ❑ Gravel Pack D Tracy Type of Casing_ Specifications <br /> IlPublic I:l Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I Eastern JAurface Seal Installed by 'tom <br /> Repair Work Done W Type of Pump State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material A .Depth OF <br /> Depth Filler Material i Depth, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-1 1 REPAIRIA"DDITION 1 1,DES_TRUCTIOf9 IrI jNo septic system permitted it public sewer is <br /> • availablri within 200 feet'IL." <br /> r _ <br /> Installation will serve: RasidenC6 ., <br /> comrriert:ral -O'the 3 AYIIA ENT <br /> Number-of living units: Number of bedrooms 'RECEIVED <br /> E <br /> Character of soli to s depth of 3 feet-. Wsq�� <br /> ftlftl <br /> SEPTIC TANK ❑ Type/Mfg Capacity No old T'Iee <br /> PKG. TREATMENT PLT.G7NTY <br /> SIGIBth�la�lldi <br /> Distance to nearest: Well Foundation Pr0"1d6HEAl_TfJ SERVICE <br /> ENVIRONMENT L 1714 D1VI'30N <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER BED © Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Ii Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina �- <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 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 compenss- <br /> tion laws of California." <br /> The applicant ca Fr required I ns. Complete drawing on seG as side. <br /> Signed X Title: _,1/ Date: �" / /_3 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ Date_ Area <br /> Pk or Grout Inspection by Date - FinalInspectionby A4111 rn/I 2 pate <br /> Additional Command: _ . . — <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 /> FEE <br /> INFO AMOUNT <br /> DUE AMOUNTREMITTED K ECEIVED BY PATE PERMIT'NO. <br /> . EH M24IRtev.final <br /> EH i�•2a I <br />