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APPLICATION FOR PERMIT <br /> r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> p 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 �• �� . <br /> P> Rl[sT E%pIRES 1 YT]s"111IR I�ROId D�'�T ISS1�� ° c <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 /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules^.and`Re&lations of San <br /> Joaquin County Public Health Services. <br /> f� <br /> Job Address _ City Lot Size/Acreage �* <br /> tom" /�7 <br /> Address r� lErL� ..ems -CA- �-'37rvPhone <br /> Owner's Name <br /> ContractorAddress.�� ���� ��''�`' License fVo.' � '--Phone �I,Z <br /> TYPE OF WELL/PUMP: NEW WELL ❑ 1WE11 REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring well C7 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES-- DISPOSAL FLD. PROP. LINE <br /> . _. --"-FOUNDATION -AGRICULTURE WELL OTHER WELL - PITSISUMPS _ �- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Ind ill. 1:1Open Bottom ❑ Manteca Dia, of Well Excavation Dia, of Well Casing <br /> Type of CasingSpecifications — <br /> omesticlPrivate ❑ Gravel Pack 0',Tracy <br /> Cl Other ©Delta,: Depth of Grout Seal Type of Grout O <br /> 1M Public ', <br /> CJ Irrigation R Approx. Depth ,r❑..£astern '� / Surface Saul Installed by <br /> H P, lState Work Done <br /> Repair Work Done L7 Type of Puitip' •- ..Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter _ r <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIRIADDITION-Cl.-DESTRUCTION I=1 iNo septic system permitted if public sewer is <br /> r ' available within-200 feet) <br /> Installation will serve: Residence— Commercial Others . <br /> Number o1 living units: Number of bedrooms -� <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK.L ❑ Type/Mfg Capacity ' No. Compartments <br /> PKG tTREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation t Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: well Foundation Property Line <br /> SEEPAGE PITS It Depth Size Number <br /> SUMPS L1 Distance to 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 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, t shall not <br /> employ any person in such manner as to become subject io workman's compensation laws of California." Contractor's hiring or sub-Contracting signature <br /> certifies the following: "I comity that in the performance of the work for wfi'rch this permit'is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must cal r all'required inspections. Complete drawing on reverse side. r <br /> ti _ Title: Date: <br /> Signed w - --- <br /> /i� ® FOR DEPARTMENT USE ONLY <br /> Application Accepted by ' Date / Area <br /> Pit or Grout Inspection by <br /> 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 AMOUNT DUE AMOUNT REMITTED CASH gECEiVEO BY DATE PERMIT,NO. <br /> INFO <br /> ,r� ? t . � { t; <br /> . EH 13-24iREY.limy j <br /> � EM,�.Ie <br />