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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 /> �RRIfT'C R%PIRES 1 --- JR IfM DA18 iSS= <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> i application is made in coagpliance vith San Joaquin County ordinance No. 549 and 1852 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City" Lot Size/Acreage <br /> Job Address <br /> Owner's Nam .� Address <br /> Phone <br /> r ^ / <br /> 1 Contract ddre )cense <br /> TYPE OF WELL/PUMP: NEW WELL ❑ -WELL REPLACEMENT C) DESTRUCTION C1 Out Monitoring Well <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> .i <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f-1 Ind trial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> omesiiclPrivate G7 Gravel Pack Cl Tracy Type of Casing Specifications,. <br /> M Public <br /> (I Other ❑ Delta Depth of Grout Seal Type.of Grout <br /> , <br /> G Irrigation Approx. Depth •❑ Eastern Surface Seal Installed by Ge` <br /> Repair Work Done {a Type of Pump 6 <br /> H.P. 9k�' — Ste Work Oon <br /> i Welt Destruction 0 Well Diameter -n <br /> Sealing Material & Depth <br /> Depth Filler Material L Depth Z <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAiRIADDITION 0 DESTRUCTION G 1N septic system permitted if public sewer is <br /> available within 200 feet.) � - <br /> + Installation will serve: Residence_-Commercial_.� Other "" <br /> Number o1 living units: Number of bedrooms- <br /> Water table depth <br /> I Character of roil to a depth of 3 feet: <br /> I ' � i Capacity t� No. Compartments <br /> SEPTIC TANK 0 Type/Mfg <br /> ti -,� Method of Disposal r <br /> 4"PKG. TREATMENT PLT. ❑ T b "'.""'_. ~�_, v . <br /> Distance to nearest:d Well Foundation' Property MAX <br /> LEACHING UNE 0 No. & Length of lines Total long th/siz <br /> jFILTER BED C:1 "Distance to nearest: Well Foundation Props <br /> iQf <br /> Number PUBU �' / ' <br /> SEEPAGE PITS 11 Depth size E€\Wbf AX AL HEALTH DIMS10`•I ' <br /> SUMPS Ll Distance to nearest: t Well Foundation <br /> € DISPOSAL PONDS 4 '❑ „t ' <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 compensa• <br /> tion laws of California." jl <br /> The appNca i all re ui 'ons. Complete drawing on re rse side. .•� � � <br /> Signed <br /> I Titin: Date: <br /> F(DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> 2l�o <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO -`, y,�y �. �c��� V <br /> G / QEH 13-24IREv,sins) 107302-' 60 T 7 Z LZ Z o <br /> EH 74.26 <br />