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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR 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 /> 67 12/ U , . <br /> Job Address City Lot Size/Acreage <br /> n <br /> Owner s Nama_i-gl _ Address Phone <br /> Contractor ' Address 7e! ] J __License No. j'f Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION 0 Out of Service Well Ci <br /> PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI 4S DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULT RE W OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS <br /> CI Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> to <br /> Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing_ Specifications <br /> I'1 Public 1:1 Other f-1 Its Depth of Grout Seal Type of Grout <br /> I I Irrigation __ Approx. Depth i Eastern _,.Surface Seal-Instatlad by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Be ing Material i Depth <br /> Depth Pi er Material L Depth <br /> TYPE Of SEPTIC WORK; NEW INSTALLATION M REPAIRIADOITION I I DESTRUCTION I ] iNo septic system permitted if public sewer is <br /> �� available within 200 lest.! <br /> Installation will serve: Residence" Commercial er <br /> i <br /> Number of living units: Number of bedrooms <br /> Cheractar of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity U No. Compartments <br /> PKG. TREATMENT PLT.0 + Method of Dispo I <br /> Distance to nearest: Well FoundationProperty Line <br /> / , _4&6 <br /> LEACHING LINE 0 No. & Length of lines S To I length/size <br /> FILTER BED 0 Distance to nearest: , Well fild ZA(rFoundation Property Line <br /> SEEPAGE PITS 11 Depth Siza NuFJbsr <br /> SUMPS Ll Distance to est: Well oundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's itignature certifies the following: "I certify tharin 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 California." <br /> The applicant mu call for all tred in tions. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> ,#Or Grout Inspection Data inal Inspection by Dat&*�� <br /> Additional Comments: �-� rgt:-54 A!4 <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 /> IFEE N AMOUNT DUE AMOUNT REMITTED CK RFCEFVED BY D TE PERMIT-NO. <br /> hu <br /> . EH M24 IREV,I/n 61 <br /> EN 14.29 1 <br /> t <br />