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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> w J ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in coaTlisnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> -I ­) / 4 <br /> ob Address <br /> (� City -� 1 Lot Size/Acreage <br /> �1 Phone <br /> wner's Name Address <br /> ontracttu �` _ Address ' " License No. Phone <br /> YPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Wel; ❑ <br /> PUMP INSTALLATION C3 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> C7 industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing <br /> fl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> F1 Public f"1 Other rl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by" <br /> Repair Work Done U Type of Pump H.P. State Work Done U7 <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> £ OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within Y00 feet.i <br /> Installation will serve: Residence_ Commercial� Other <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 fest: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg L Capacity—L19--o No. Compartments <br /> PKG. TREATMENT PLT. ❑ f- Method of Dispogal <br /> Distance to nearest: Well terd F undation X0 Property Line g� t <br /> LEACHING LINE No. & Length of lines r Tgtai length/size 0�, 16 <br /> FILTER BED ❑ Distance to nearest: Well 6t7 Foundation 30 Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> MPS UI Distance to nearest: Well Foundation Property Lino <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 rogufations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such men r as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies t wln "I certify hat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion of Califor <br /> The a cat or r ad inspections. Complete drawing on reverse side. <br /> Sig Title: �'�— Date: <br /> FOR DEPARTMENT USE ONLY 1 �7!`�r� <br /> Application Accepted by Date " �Z Area61 <br /> 4 <br /> Pit or Grout Inspection by Aj Date Final In ction Data -� <br /> Additional Comments: !x/��(14 1'"yti <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE I <br /> INFO AMBODUNT DUE AMOUNT REMITTED CASH Q. <br /> RECEIVED BY DATE PE�IRMIT'NO. /�' <br /> + EM 13 74 EH 13.14 JREV.rte SI 7_a 3" 9,4 — 3 SD <br /> l <br />