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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-344-73442-0 <br /> 3AR rgQg DATE I SSUg <br /> ' <br /> (Complete in Triplicate) <br /> Application is hereby made to Sae Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in ceo;�liance with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City W,�7%kLot Size/Acreage r' <br /> Owner's Name - Address Phone ` <br /> Contractor <br /> Address License No. 1-11��Phone- t� <br /> TYPE OF WELL/ UMP: NEW WELL 0 WELL REPLACEMENT C_ DESTRUCTION ❑ Out of Service Well. ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE:WELL OTHER WELL PITS/SUMPS <br /> A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications_ <br /> 3 PLiblic Cl Other ❑ Detta Depth of Grout Seal Type of Grout <br /> CJ Irrigation —Approx. Depth n Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. Slate Work Done ._ <br /> Well Destruction ❑ Well Diameter' Sealing Material i Depth <br /> Depth I Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1-4 REPAIR/ADDITION �_I DESTRUCTION Ci lNo septics stem <br /> y permitted it public sewer is <br /> installation will serve: Residence � Commercial— Other available within 200 feet.) <br /> Number of living units: ._ Number of bedrooms <br /> Character of coif to a depth of 3 feet: <br /> SEPTIC TANK. Water table depth <br /> ❑ TypeJMfg. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ' <br /> / Method of Disposal <br /> Distance to'nearest: Well Foundation. ` Property Line <br /> l O <br /> I <br /> LEACHING LINE ❑ No. 8 Length of lines <br /> Total length/size <br /> FILTER BED CI Distance toynearest: W5"Poundati <br /> i _ Propeny Line <br /> SEEPAGE PITS 11 Depth t Size <br /> SUMPS Number <br /> LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby cenify 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: <br /> emplo an �I certify that in the performance of the work for which this permit is issued, I shall not ' <br /> Y y person in such manner as to become subject to workman's compensation taws 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." <br /> The applicant must call for all required inspections, Complete drawing on reverse side. <br /> Signed X Title: <br /> Date: <br /> FO DE ENT USE ONLY <br /> Application Accepted by Date 7A <br /> Area <br /> PitorGrout Inspection by Dace Final Inspection b <br /> Date <br /> Additional Comments: - <br /> Applicant - Return all copies to: SAN JOAQOIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVf <br /> ON PERMIT/SERVICES <br /> 44IN SAN JOAQUIN,RONMENTAL TP OI BOX 2009,5 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT VUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVeD BY iATE PERMIT'NO. <br /> . FH 172/IAEV.+inyi [ l ��^ <br />