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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 <br /> PERMIT UEIRES 1 YEAR IOM DATE I§SUM <br /> (Complete in Triplicate) <br /> Application is hereby mads to San Joaquin County for a permit to construct and/or install the work herein described. This , <br /> application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules Lad Regulations of Ban <br /> Joaquin County Public Health Services. <br /> Job Address City 64MMLot Size/Acreage <br /> /moo l <br /> Owner's Name r�Nt---.> -.2 f �� AddressAl Phone <br /> v <br /> Contractor Addres r �e nee M,rsr ��Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION 0 out of Service well1/1 Gl , <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing "— <br /> U Domestic I Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications <br /> * Public 11 Other 0 Delta Depth of Grout Seal Type of Grout <br /> G litigation — Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H,P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material A Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIRIADDITION DESTRUCTION CI INo septic sysiam permitted if public sewer is <br /> available within 200 feaLl <br /> installation will serve: Residence & Commercial_ Other <br /> Number of living units: .....,. Number of bedroomst <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLT, C1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. b Length of lines Total length/size <br /> FILTER BED n Distance to nearest. Well Foundation �— Property Line 4::2 <br /> SEEPAGE <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll 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 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 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." <br /> The applicant must call for all required in Clio S. Complete rowing on�reverse <br /> aside. <br /> Signed Title: Date' <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by _ l t ��- - _ Date <br /> Pit or Grout Inspection by Date Final Inspection b Datef <br /> Additional Comments <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> I, 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 <br /> r <br /> FEE AMOUNT DUE AMOUNT REMrTTED CK RECEIVED BY DATE PERMIVNO. <br /> INFO CASH <br /> EHt3-24IPIEV.t/A$) (� p16g3 <br /> E}{,4,26 <br />