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APPLICATION FOR PERMIT <br /> S w <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BO% 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 <br /> D'CiitHTT �;XPIRSS 1 YEAR i�RON DATA_.I�$VJ� , <br /> (Complete in Triplicate) <br />'L Applicstion ie hereby made,to Eau 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. 544 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.. ,. <br /> City Rt Lot Size/Acreage <br /> Job Address �} <br /> Owner's Nam - <br /> Address r. _ _ _ Phone <br /> Contractor Address License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ <br /> 7PUMP NEW <br /> ❑ SYSTEM REPAIR ❑ OTHER ❑ - <br /> Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I <br /> Cl Industrial ❑ Open Bottom ❑ Manteca `-' Dia. of 1NeII Excavation Dia. of Well Casing <br /> ,C) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications• - <br /> Type of Grout <br /> C3 Public I:1 Other ❑ Delta Depth of Grout Saar _ <br /> r CJ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done \ <br /> Sealing Material Z Depth <br /> Well Destruction ❑ Well Diameter <br /> Depth Filler Material &;Depth <br /> ' ve TYPE OF SEPTIC WORK; ^NEW INSTALLATION REPAIRIADDITION Cl DESTRUCTION F aseptic system permitted i1 public sewer is �51 <br /> 4� available within 200 feet.l <br /> P� <br /> Installation will serve: Residence .2L Commercial— Other.—.-- <br /> Number <br /> ther. -Number of living units: .!.. Number of bedrooms —2= ! <br /> Lr Character of sail'to a-depth of 3 feet: Water table depth <br /> SEPTIC TANK ' ❑ TypalMig Capacity2 62 LY? .-_. No. Compartments <br /> PKG. TREATMENT PLT.CTS r Method of Dispo al <br /> Distance to nearest: Well Founds Property Line <br /> LEACHING LINE -"6No. $ Length of lines Total length/size <br /> ! <br /> ;-FILTER BED C1 Distance to nearest: Well i F Faundation f roperty Line <br /> f <br /> r <br /> SEEPAGE PITS I I Depth Size "^ Number <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 Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the following; "I cartify 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 /> canities 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 compenss- <br /> tlon laws of C rnla." <br /> The app' an m calf r sl &red ins n omplete drawing onreverseside. <br /> ' Signsd Title: Date: <br /> -�� ?t� <br /> r <br /> Zn!UARTMENT:USE 0f11LY <br /> !R <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date ` r r <br /> Y <br /> Additional Comments: f <br /> Applicant Return all copies to: BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/,SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STUCKTON, CA 95201. <br /> c:. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED-0V DATE PERMI7'NO. <br /> INFO <br /> . EH13-2404EV.rin51 <br /> EH i�•Ztl <br />