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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> f P O BOX 2009, STOCKTON, CA 95201 <br /> rPERM T EXPIRES 1 YEAR FROM DATE I <br /> 1 (Complete in Triplicate) <br /> t construct and/or install the work herein described.. This <br /> s permit to <br /> Application is hereby rltade,l:o San Joaquin County for pe <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Josquia Count Public Health SeE <br /> es. <br /> City Lot Size/Acreage <br /> Job address <br /> r Phone �A--Owner's Name. Address �]�r�/ <br /> /I `� �y �� l ease No. phone qj - y <br /> TYPE Of WEPUMP: NEW WELL WELL REPLACEME T ❑ DESTRUCTION 0 Out of Service Well 0 <br /> LL/ ' <br /> N SYSTEM REPAIR Z] OTHER ' Monitoring Well C7 <br /> PUMP INSTALLATION D <br /> DISTANCE TO NEAREST: SEPTIC TANK // SEWER LINES DISPOSAL FLD. �PROP. LINE <br /> FOUNDATION AGRICULTURE WELL s OTHER WELL -tom PITS/SUMPS <br /> ►° . <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION Sf EGIFICATIONS— " <br /> C7 dustrisl O Open Bottom D Manteca Dia. of Well Excavation <br /> pia. of Well Casing <br /> mastic/Privste C1 Gravel Pack n Tracy Type of Casing_1. �- Specifications <br /> ['1 Public Cl Other <br /> Fl. fl Delta Depth of Grout Seal Type of Grout <br /> _Approx:�D I astern urface Said Installed by <br /> I I Irrigation + <br /> H.P. Stats Work Do <br /> Repair Work Done U Type of Pum <br /> r sealing Material i Depth <br /> Wel! Destruction -0 Well Diameter <br /> Depth tiller Material i Depth' --�-- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-1 1 REPAIR/ADDITION i I DESTRUCTION-1-i-iNo septic system permitted if public sewer is <br /> available within 200 feet) ; <br /> r <br /> Installation will serve: Residence' ce E--Commercial Other <br /> Number of living units: !� Number of bedrooms } <br /> Water table depth <br /> I Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. <br /> Method of Disposal <br /> G1 _ <br /> Distance to nearest: Well Foundation Property Line i <br /> -LEACHING LINE Cl No, 8 Length of linea Tota! length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line IS,- <br /> SEEPAGE <br /> SEEPAGE PITS 11 Depth 't Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line f <br /> DISPOSAL PONDS O € <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 Sen Joaquin County [[[ <br /> Home owner or licensed agent's signat.ure certifies the following: "I certify that in the performance of the work for which this permits issued, !shall not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub ontracting 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 wI rkrtan's compensa <br /> tion laws of California." i <br /> The applic must call f firedj <br /> pections. Complete drawing on re er side. <br /> 7� <br /> Signed Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY 0 <br /> I <br /> '�Date v Area <br /> Application Accepted <br /> by CA— r•---F --�— � <br /> r..-,..Y <br /> Pit or Grout Inspection by Date Final Inspection by�� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health ServicesI� <br /> Environmental Health Permit/Services44 <br /> 445 N San Joaquin, P O Box 2409, Stkn, CA 95201 <br /> FEE AMOUNT DUE; AMOUNT REMITTED K CEIVED BY DATE PERMIT'NO. <br /> INFO � _ <br /> . EN 5E-2411IEV,$IKai ®� <br /> I EH 14.26 - - <br />