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,1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 1 (209) 468-3447 <br /> iPERMIT EXPIRES-1 YEAR rROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to Sass Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cotapliance Vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> FJobAddress <br /> ounty Public Health Services. <br /> 4 Z)O\ 9 , V City S�Cajj Lot Size/Acreage <br /> mo AddressPhone <br /> 2-©9 <br /> Ls�Address 3 t License No.� Phone—TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION E AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM.AREA CONSTRUCTION SPECIFICATIONS <br /> 17,71 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> * Domestic/Private _ ❑ Gravel Pack" n Tracy: L Type of Casing - Specifications <br /> R Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CI Irrigation —.Approx, Depth ❑ Eastern' 'Surface Seal Installed by N <br /> Repair Work Done U Type of Pump, H.P. State Work Done_ <br /> Well Destruction D Well Diameter Sealing Material i Depth ,� t <br /> Depth ;f Filler Material i Depth \ Sy <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION (No septic system permitted if public sewer is <br /> I / available within 200 feet.) <br /> Installation will serve: Residence_i Commercial— Other <br /> s <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: -'I * Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg 41 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ o- Method of Disposal <br /> Distance to nearest: ,Well Foundation Property Line <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED n Distance to.nearest:, Welt -Foundation Property Line <br /> SEEPAGE PITS 11 Depth I Size Number l <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ {� <br /> I <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 /> Home owner or licensed agent's signature eereifies 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 to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting 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." '1 1 <br /> )i(The applicant mutt call for all required i ctions. Complete drawing on reverse side. <br /> Signed X Title: Data: <br /> DEPARTMENT" USE ONLY <br /> TApplication Accepted by Date q t <br /> l Area r <br /> 3 <br /> Pit or Grout inspection by Date Final Inspection by Y U/ Dots 5U <br /> Additional Comments: <br /> Applicant - Return all copiers to: ',SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH DECEIVED BY DATE PERMIT'N0. <br /> . fH1,. IREV.srHSI ur `� r �]� l/ �- .]—[ V go—,235 <br />