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APPLTCATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> t 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> ! P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED- <br /> i (Complete in Triplicate) � <br /> I u n Count for a permit to construct and/or install the xork herein a4-r &-��this <br /> Application is hereby compliance <br /> San Joaquin Y i <br /> application is made in eat4pliance xith Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San . <br /> Joaquin County Public Health Be i ear <br /> US <br /> Job Address <br /> City eLot Size/Acreage <br /> (} <br /> .- <br /> -V Address <br /> ;. <br /> Owner's Name-- - - <br /> Phone <br /> g <br /> Contractor <br /> O tees r U � icense Na. ` <br /> TYPE 4F WELL/PUMP: NEW W L ❑ WELL REPLACEMENT C7 DESTRUCTION El Out of Service Well LI <br /> PUMP INSTALLATION^❑ ; <br /> �� - - SYSTEM REPAI C7 OTHER ❑ Monitoring Well [3 E <br /> DISTANCE TO NEAREST: SEPTIC TANK} .�SEWER LINES DISPOSA FLD. PROP- LINE <br /> FOUNDATION AGRICULTURE WELL 0 WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC SPECIFICATIONS t" Dia. of Well Casing 4 <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. o ell cavation � Specifications. - <br /> 11 Domestic/Private 0 Gravel Pack ❑ Tracy of Ca ng_ <br /> !-1 Other , [l De1ta�!_ Depth of rout Seal Type of Grout <br /> I'1 Public I <br /> I I Irrigation _ .Approx. Depth I I Eastern Surface eaI Installed by <br /> Repair Work Done U Type of Pump`. N.P. State Work Done <br /> Sealing Naterial i Depth <br /> Well Destruction ❑ Well Diameter -- "r Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRlADDITION I I DESTRUCTION l I (No septic syste par iu d it public sewer is <br /> available within t <br /> Installation will serve: Residence— Commercial_;Other_-. �� '� ►j <br /> S 1 A <br /> Number of living units: Number of bedrooms V <br /> Character of soil to a depth of 3 feet: +f Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity U- No. Compartments <br /> .r "" -' Method of Disposal <br /> PKG. TREATMENT PLT.❑ r {1. <br /> Distance to nearest: Well ' Foundation Property Lina <br />' LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Lina S <br /> I SEEPAGE PITS 1,1 Depth 2 Size mbar <br /> SUMPS -LI Distance to neo V ,tNell, Fo nu dation `Property Line <br /> DISPOSAL PONDS ❑- <br /> I hereby certify that I have prepared this application and that the work will Lie done in accofdanco-ith--San Joaquin county ordinances, state laws, end <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 /> amp k�y 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 isuui7lshhall amplay-persons subject to workman's eomponss- <br /> tion laws of California." -" ! <br /> i The applicant t can for all r ed ins ions. Complete drawing on reverse side.- . <br /> Signed 1 <br /> Title: Date: <br /> - OR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date <br /> " Pit or Grout Inspection y1 - Date Final Inspection Dattf� <br /> Additional Comments: t;' <br /> Applicant -Return all copies to: San Joaquin County Public Health Services ` <br /> Environmental Health Permit/Services ' <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE'' PERMiT'NO. <br /> I`r INFO <br /> 3 EM 13.34(REV.riMSi 1� ,' © . — b+ <br /> en 14.36 �l 1v <br />