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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV I CA") <br /> g-I <br /> ENVIRONMENTAL HEALTH DIVISION is <br /> R 0 BOX 2009, STOCKTON, CA 95201 JAN <br /> . 2. 4 <br /> (209) 468-3447 <br /> PERMIT EXPIM I MAR rRQM PATH <br /> (Complete in Triplicate) <br /> L"v . <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance 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 -�O <br /> City��� Lot size/Acreage <br /> A3:2 <br /> Owner's Name Address Phone <br /> Contfacto Address jggdjj� License N!J� Phone l <br /> TYPE OF WELLIPUMP. ... NEW WELL C WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well 0 <br /> . PUMP INSTALLATION k L-SYSTEM REPAIR 0 OTHER C Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .- ---_ DISPOSAL FILD.— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL— PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �omssfic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public C1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> M Irrigation —,Approx. Depth 0 Eastern Surfico Seal Installed by <br /> Repair Work Done 91 Type of Pump H.P State Work Done <br /> Wait Destruction 0 Well Diameter Sealing Lia OA&I & Depth <br /> Depth Filler Wstirial 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 0 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:f Residence— Commercial— Other <br /> Number of living units: — Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK C1 type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> _Distance to nearest: Well Foundation__Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/Sir <br /> FILTER BED n Distance to nearest: Well Foundation— Property Line (114 <br /> 0 <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line P <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this Opplic0tion 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 i <br /> Home owner or licensed agent's signature certifies the following: "I comity that in the performance of t'he 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 of sub-contracting signature <br /> certifies the following: 1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's cornponsa• <br /> tion laws of California." <br /> The applicant must I for all req "red inspections. Complete drawing on reverse side. <br /> 40 <br /> Signed X. Title: Date: L 2-0 <br /> /FOR DEPARTMENT USE ONLY <br /> Application Accepted by A., Date 00 <br /> Pit or Grout Inspection by Date Final.Inspection by Dat <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 0 BOX 2009, STOCKTON. CA 95201 <br /> FEE <br /> INFO CAMNT DUE T REMITTED CASH RECEIVED By DAT ERMIT'NO. <br /> EN 13-24(REV.I Y as) 4T,OUAMOUNREtry G. <br /> t H <br />