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APPLICATION FOR PERMIT <br /> f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` <br /> . = + ENVIRONI6ENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> i' 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �j r <br /> Job Address v City Lot Size/Acreage <br /> mb <br /> Owner's Name WAddr Phone <br /> -��- <br /> ss 4 ; f ase No. I Phone z- <br /> 1 ��Q� <br /> TYPE Of WELL/PUMP: NEW WE L ❑ WELL REPLACEMENT n DESTRUCTION C3 Out of Service well ❑ <br /> PUMP INSTALLATION 0 SYSTfMiREPAI OTHER ❑ Monitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES F DISPOSAL FLO. - PROP.. LINE <br /> FOUNDATIvN`} "�"� AGF CULTURf WELL" �"""'""OTHER-WELL- "'""''—PITWSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS •. <br /> C] I dustrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation_� Dia.,of Well Casing <br /> _`�Vomestic/Private ❑ Gravel Packer. ❑ Tracy Type.of Casing_ Specifications <br /> V] Public i. l_1 Other I Fl Delta Depth of Grout Seal , Type of drout <br /> + <br /> 1 1 irrigation —.Approx. Dt Eastern Surface Seai Installed by <br /> e� <br /> Repair Work Done ' U Type of Pump ' •H.P. State Work Don <br /> Well Destruction F ❑ Well Diameter 'I Sealing Material i Depth t <br /> Depth 11 Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION l I REPAIR/ADDITION.`I I DESTRUCTION I i iNo septic system permitted if public sewer is f <br /> .� available within 240 feet.)�. I { <br /> Installation will serve: Residence___ P Commercial_' Other V' <br /> Number of living units: NumbI bedrooms y , <br /> Character of soil to a depth of 3 feet: ` ' } Water tabk depth �� Q <br /> SEPTIC TANK ❑ Type/Mfg ! Catpacity No. Compartments { <br /> PKG. TREATMENT PLT. ❑ �'1 if Method of:Disposal <br /> Distance to nearest: Well, Foundation rProperty-Line —�- - <br /> LEACHING LINE 0 No. a Length of lines { Total length/size <br /> FILTER BED ❑ Distance to nearest:. Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number r <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby candy that I have prepared this application and that the work wilt 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall notNII <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 r <br /> certifies the following:"I ce ify 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 /> Thea t at call for uired Inspections. Complete drawing on rev r side. <br /> Sig Title: Date: 5 <br /> FO EPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by 1(� Date Final Inspection by Date / 3 <br /> Additional Comments: `+ <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I <br /> K RECEIVED BY DATE PERMIT'N0. <br /> INFO CASH <br /> I <br /> -� e <br /> . EH 13-24 taty.„H s, -� �� c7 LiS'.O g-(, 2 2 <br /> EH 14.25 <br />