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a APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES a4 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> r <br /> > P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <, <br /> REMIT EXPIRE9. I MAR rRQM RATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County fora 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 1662 and the Rules ankliegulationa of San <br /> Joaquin County Public Health.8ervices. , <br /> Job Address r City Lot Size/Acreage <br /> �r <br /> Owner's NameAddress Phone <br /> Contractor-,- Address powwc '� �`' License NoPhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well Gl <br /> PUMP INSTALLATION SYSTEM REPAIR �K, OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST:'SEPTtC T/1NK' SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATI614_:2 - AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> omestic/Private 0 Gravel Pack 0 Tracy .Type of Casing Specifications <br /> 0 Public .. 1:7 Other ❑ Delta Depth of Grout Seal Type of Grout -� <br /> CJ Irrivation Approx. Depth ❑ Eastern ' Surface Seal installed by <br /> { Repair Work Done 0—Type of Pump ,.4=6�— H.P. /T f+t ut - _ _-_ State Work Done <br /> Well Destruction 0 Well Diameier , Sealing Material i Depth <br /> Depth _ ' ' '� 1 -Piller Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION Ll REPAIR/ADDITION 0 DESTRUCTION CI [No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> r <br /> Installation will serve: Residence -::_.. Commercial= Other <br /> 1 Number of living units: Number of bedrooms' �. .k <br /> -, L <br /> Character of soil to a depth of 3 feet: i .r Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No:Compartments <br /> PKG. TREATMENT PLT.Cl q Method ofrDisposal <br /> Distance to nearest: i Well Found-ation �'` Property Line . <br /> LEACHING LINE ❑ No. 3 Length of lines Total length/size `s <br /> FILTER BED M Distancetonearest: Well Foundation Property..Line <br /> SEEPAGE PITS 11 Depth 'I Size Number <br /> SUMPS LI DistancWto nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - <br /> I hereby certify that i have prepared this application and that the work will be done in accordance withr San Joaquin county ordinances''state laws, and <br /> (vies and regulations of the San Joaquin County ra <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance ot,the work for which this permit is issued. I sliall.not <br /> employ any person in such manneras to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> canities.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 /> tlon laws of California." <br /> The applicant m I for'all req 'red inspections. Complete drawing on reverse side". ^� <br /> Signed }L- I -' ---- Title: _ Datee <br /> F <br /> + OR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> r <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> t 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERMIt'No. <br /> INFO -o CASH <br /> . EH i3.2�iItEV,iiwsi � !/ I M <br /> Ett 1�•le r <br /> i <br />