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APPLICATION FOR PERMIT <br /> "-' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION A <br /> P O BOX 2009, STOCKTON, CA 95201 e8� •�I <br /> (209) 468-3447 <br /> PERlf9I T EXPIRES l YEAR 1F ROIL_ DATE I S SUBI�� <br /> (Complete in Triplicate) oU / <br /> Application is hereby made to Sen Joaquin County for s permit to construct and/or lasts)) the vo <br /> �r,IV <br /> �0 This <br /> application fe made in comp !4ed. <br /> liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules an of San <br /> Joaquin County Public Health Services. <br /> Job Address .�� � ; �J� Cit Lot Size/Acreage <br /> Owner's NameAddress * _ Phone <br /> Contractor �: Address '.7License NOVf �Phone -Ov' <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER )i. Monitoring well {� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 07HER'VVELL ':PITSISUMPS' '"` — J <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 9 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> C Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> C.1 Irrioation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump d,&& H.P.Q6 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material & DepthlY <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION fl REPAIR/ADDITION CI DESTRUCTION 0 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial — Other <br /> I <br /> Number of living units: Number of bedrooms -) % 'J� <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. . ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT P0. ❑ Method of Disposal <br /> -Distance to nearest: Well •-Foundation Property Line 1 <br /> LEACHING LINE b No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest. Well Foundation Property Line <br /> �f I <br /> SEEPAGE PITS 11 Depth Size Number <br /> l <br /> SUMPS LI 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 signaturecertifies the following, 1 comity that in the performance of the 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 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 m at call for all re d inspections, Complete drawing on reeve rse side. / <br /> Signed x.,, Title: i�tl�t/ Date- <br /> FOR <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by 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 2008, STOCKTON. CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO a� CA/ASH `p J <br /> . EH 13.2' "V.I/Mel / � Y�✓ ��r 0 1.4� <br /> EM m{•26 1 <br />