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APPLICATION FOR PERMIT <br /> USAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL H 16 <br /> HEALTH DIVISION ., a <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> t (209) 468-3447 "w <br /> RAM •EXPIRES_1YEAR FROM DATEI ESSUVIR ONMENTAL HEALTH <br /> (Complete in Triplicate) + �. WIT/SERVICES <br /> I <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 compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> r t <br /> Job Address City ,e2J1!9rt19�/9' Lot Size/Acreage �CP_d, <br /> Owner's Name F <br /> C O Address <br /> Phone <br /> Contractor- ddress S% <br /> ense No.32�--�Phone <br /> r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ <br /> I PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLO. PROP. LINE <br /> F_OUNDAT16N AGRICULTURE WELL BOTHER WELL. -PITS/SUMPS. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl tridustriai ElOpen Bottom ❑ Manteca Dis. of Well Excavation Dia. of Well Casing z <br /> U Domestic/Private _ ❑ Gravel Pack ❑ Tracy Type of Casiri9' ti Specifications_... <br /> 0 Public V1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> CI Irrigation Aplxox: Depth ❑ Eastern Surface Seal Installed by r <br /> Repair Work pone U Type of Pump H.P. State Work Done <br /> Well Destruction Z. Wall Diameter --4l Sealing Material i Depth <br /> Depth —7D~ Filler Materials Depth <br /> l TYPE OF SEPTIC WORK: NEW INSTALLATION n REPAIR/ADDITION 0 DESTRUCTION 0 (No se tics stem <br /> 1 p y permitted if public sewer is <br /> '/ _- available within 204 feet.) <br /> Installatjon will serve: Residence Commercial— 'Other <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of 3 feet,I ; Water table depth <br /> f SEPTIC TANK. 0 Type'Mfg Capacity J No. Compartments <br /> PKG, TREATMENT PLT, 0 � Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ✓. <br /> LEACHING LINE Cl No. & Length of lines <br /> Total length%size <br /> FILTER BED n Distance fo nearest: Welt - --Foundatilin"- - <br /> �Property Line <br /> j SEEPAGE PITS 11 Depth I SizeNumber <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br />'., I hereby certify that 1 have-prepared-this`-ipplicafiorri and-that the work will--be-done in accordance with San Joaquin county ordinances,+state laws, endT <br /> rules and regulations of the San Joaquiri(County <br /> Home owner or licensed agent's signature certifies the foElowing; "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 to became subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> eartifies the following; "I canif 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:" t <br /> The applic t m t c r requir t ns. Complete drawing on reverse side, I + <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 7Date ea ;Z /,?,Pii or Grout inspection by Date Final Inspection b �`D <br /> Additional Comments; }I <br /> Applicant - Return all copies to: ISAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1a<ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> ',945 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y <br /> CASH DATE PERMIT'NO. <br /> . EM 1'' (REV.tin01 Q�v ' d - <br /> rV <br />