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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 /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEARFROM DATE_ I$SUED <br /> (Complete in Triplicate) } <br /> i <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in made in compliance with San Joaquin Cou9ty Ordina o. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Co lie Heal h Services. 1 <br /> Job Addre V City Size/Acreage j <br /> LIer's Na &Mmda� <br /> me Address r ° �` -1 Phone <br /> 4 <br /> �"( <br /> ti e rte ' <br /> TYPE Of WELL/PUMP: NEWWELL WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR © OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE } <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS `� I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 I dustriel ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> !i'1 Public 11 Other . _� fl Delta "`"'""`LDepth of Grout Seal Type of Zrout <br /> I i Irrigationt �.Approx. Do th I I stern t, pu ace Seal Installed by <br /> RepaiyWork Done U Type,bf'Pump H.P. ` l _ State Do <br /> Wall Destruction ❑ Well Dia "ter I Sealing Naterial ii Depth <br /> Depth "` iriller,Naterial i Depth L �� <br /> i <br /> TYPE OF SEPTIC WORK: NEWANSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation,will serve: Resid nce_._._ -,Commercial_ Other <br /> Number of living units: Number of bedrooms = <br /> Character of son to a depth of-3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ e" - Method of Disposal <br /> Disltancelto-nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length o1 lines Total length/size <br /> FILTER BED Cl Distance to nearest: _„^,Well - -Foundation Property Line <br /> SEEPAGE PITS I I Deptfi'"=� $ize r Number <br /> SUMPS Ll Oistaaca_to.nasrest: 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 cenifiee the following: "I certify that in the performance of the work for which this permit is issued, I shell not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the folb*wwng: " certify at in the pirfo"rice of the work for which this permit is issued, I shall employ persons subject to workman's co penss- <br /> tion laws o1 6rnia." <br /> ---�--- -- .� �. <br /> Tha applic sit Call to i in tions. Complete drawing on r arse si <br /> Sig Titl Date: <br /> r <br /> j FOR DEPARTMENT USE ONLY <br /> Application Accepted byDate Araa <br /> a •� 1 <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 Pu is Health Services <br /> Environmental Health it/Services <br /> '445 N. San Joaquin O bx 2008, Stkn, CA 85201FEE ` <br /> Z9, <br /> OUNT DUE AMOUNT REMITTED K H D ECEIVED BY TE RMIT NO. <br /> a EN 13.24 I#EV.t/96 ✓' °�. /}�J !I <br /> EN 11.20 lam(/ LL <br />