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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , <br /> ENVIRONMENTAL HEALTH DIVISION <br /> gTON CA 9520 . " Y <br /> 2009 STOC "'01V <br /> P O BOX , � . <br /> (209) 468-3447 SEA 0 8992 <br /> (Complete in .Triplicate) �.I��f4 01�_MENTAL.HEALTH <br /> ES <br /> PWNT�Sn�� <br /> Application is-heireby made 'to San Joaquin County for a permit to construct and/or install th erein described. This <br /> spplicatioo°ia made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County'Public Health services. t <br /> City Lot Site/Acreage <br /> Job Address i <br /> Address Phone <br /> Owner's Name . - ` <br /> J <br /> cnse Phone <br /> Contracts ddre �vL <br /> : <br /> TYPE OF WELLIPUMP: Monitoring'We'll a1, NEW WELL ❑ <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of 5ervice'We11 .❑ <br /> SYSTEM REPAIR OTHER 01 <br /> eEll [.3PUMP INSTALLATION ❑ �,,.�_--�.--T <br /> fez DISPOSAL FLO. PROP.-CINE <br /> DISTANCE TO NEAREST: SEPTIC TANK " SEWER-LINE PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Ind tai ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestielPrivate ❑ Gravel Pack C1 Tracy Type of Casing Specifications <br /> _ Type of Grout <br /> M Public 1-11 Other ❑ Delta Depth of Grout Seal <br /> CJ Irrioation Approx. Depth ❑ astern dace Seal Installed by <br /> Repair Work Done 0 Type of Pump � H•P• State Work Done <br /> Well Destruction ❑ Well Diameter } Sealing Material Z Depth ; <br /> Depth Filler Material 4 Depth , <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATION rl REPAIR/ADDITION 0 DESTRUCTION G iNo septic system permitted if public-"sewer.is _ <br /> available within 200 leet.l <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth o!3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacityt ; Not'Compdrtments <br /> PKG. TREATMENT PLT.Cl � 'Mathod of Disposal <br /> Distance to nearest: Well Foundation 'Property Line <br /> -,L"TEACHING LINE ❑ No. & Length of lines Total longih/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS.,. �Ll Oistanco-to nearest:—.-:Weli---=-_--. •Foundation --` -=-Property-L-ins—1 -� <br /> DISPOSAL PONDS ❑ A y # <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 Sari 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." t <br /> The applicantZrn�>11�Ajll required inC coons. Complete drawing on rev is side. <br /> Signed <br /> Title: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date. Area <br /> � o � rlZr <br /> Pit or Grout Inspection by Date Final.Inspection by Data <br /> i <br /> Additional Comments: <br /> ' Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -'r <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES =�'� <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 <br /> FEE AMOUNT DUE AMOYNTREMITTEDCK ECEIVED BY DATE ,NO. <br /> INFO 1ILI <br /> ' <br /> EH 13-24 MEV,t/M5l DO 46 C0� {� <br /> i <br /> 1 - <br /> 5 - <br />