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APPLICATION FOR PERMIT " <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> f. rJ _ b <br /> ENVIRONMENTAL HEALTH DIVISION AY <br /> P 0 BOX 2009, STOCKTON, CA 95201. ��� g � LTH <br /> � <br /> (209) 468-3447 ' "1liR0INMiE T, { <br /> (Complete in Triplicate) <br /> r <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 ccatpliance:with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health/402,-Z Services. <br /> r <br /> Job Address � ' '` - -[ <br /> City Lot Size/Acreage <br /> Owner's Name <br /> Address Phone <br /> Contractor Address License No. Phon <br /> i ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Li Out of Service Well Ll <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR ❑ OTHER Q Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Indu vial (D Open Bottpm Dia, of Well Casing❑ Manteca Dia. of Well Excavation g <br /> r omestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> { . <br /> M Public fel Other � �{ `� �❑ Delta Depth of Grout Seal Type of Grout <br /> I cl irrigation Approx.:Oepti�­O Eastern.. -- .-.Suriaea Seijl Installed by of <br /> 5Yl <br /> Repair Work Done L] Type of Pump_— H•P• State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material i Depth <br /> Depth EFiller Material i Depth <br /> i ave TYPE OF SEPTIC WORK: NEW INSTALLATION n REPAIRIADDITION MDESTRUCTION G septic system permitted if public sower is <br /> - available within 200 lest.! <br /> installation will serve: Residence Commercial Other <br /> Number of living units: Nurrtber of bedrooms <br /> Character of*oil to a depth of 3 feet; i Water table depth <br /> SEPTIC TANK - ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> t FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth 'I Size Number A <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL. PONDS O <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 /> r 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 manner as fo become subject to workman's compensations laws of California:" Contractor's hiring or subcontracting 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 must ce f all requif�d ' pections. Complete drawing on re rse side. <br /> Signed Title: <br /> Date: -3p <br /> FOR DEPARTMENT USE ONLY <br /> ' Application Accepted by Date �/ Area J� <br /> Pit or Grout Inspection by f Date Final Inspection by Date /K <br /> Additional Comments: <br /> T <br /> Applicant - Return all copies to* SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> } ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> II 445 N SAN JOAQUIN, P 0 BOX 09, STOCKTON, CA 95201 <br /> i <br /> FEE <br /> l FO A/MOUNT <br /> DUE /nAMOUNT REMITTED /CA5H RECEIVED 8Y DATE QPERyrMIT NO. <br /> . EH 15-2 iREV.tinSi b r'`Q�'f -7 { �1�0021 <br /> EM 7{•25 <br />