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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FRgM DATE ISSUM <br /> (Complete in Triplicate) <br /> f Application is hereby made"to.Sen 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 1862 and the Rules sad Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address �- <br /> 7ld City Lot Size/Acreage <br /> Owner's Name <br /> Address - - Phone <br /> Contractor Address � License Not Phone �y' <br /> TYPE Of WELL/PUMP:P: NEW WELL ❑ WELL REPLACEM T ISI DESTRUCTION 0 Out l+f service <br /> Well 0 <br /> Nell ❑ <br /> I PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER D <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial ❑ Open Bottom 0 Manteca I. Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Pri,rste 0 Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> 1'1 Public Cl Other n Delta , Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done L7 Type of Pump H.P. -State-Work-Done <br /> Well Destruction © Well Diameter Sealing Material i Depth <br /> Depth Piller Material i Depth ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I.INo septic sy�st_em_�,,_, rmilted if public sewer is <br /> available within <br /> Li <br /> Installation will serve: Residence J Commercial_ Other <br /> Number of living units: Number of bedrooms CF <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg 1' Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ 1 Method of Disposal <br /> } <br /> Distance to nearest: Well - Foundation Property One <br /> } <br /> LEACHING LINE Ll No. 6 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well .Foundation Property Lina <br /> SEEPAGE PITS 11 Depth 9,4' -- SizeNumber _ <br /> SUMPS LI Di l tancs to nearest: Wel +Foundation,70r p_'-Property Line <br /> DISPOSAL PONDS ❑ /'a -( l� a! <br /> I hereby certify that 1 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 I <br /> Horne owner or licensed agent's signature certifies the following: "I certify that in the periormanci•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 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(PUSLAyl f r all:requ 1 spgctions. om Brewing on reverse side. <br /> SignedX. Title: _� - Date: <br /> FOR DEPARTMENT USE ONLY <br /> G4�. <br /> Application Aecapted by Data y/� �Z Area <br /> Pit or Grout Inspection by Date Date <br /> Final inspection by j Z <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> r Environmental Health Permit/Services <br /> r 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK ECFIVEO BY ATE PERMIT NO <br /> INFO <br /> EH 14.38 <br />