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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRON14ENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERiIIT .EXPIRES 1 YEAR VROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application ia'hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is trade in compliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. + <br /> Job Address City Lot Size/Acreage <br /> l <br /> Owner's Name Address � --- — Phone <br /> Contractor Address Icense No.4717.12' <br /> TYPE OF WELL/PUMP: NEW WELL W WELL REPLACEMENT I- DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION e SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well G7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial © Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> C110omesticlPrivate LTl Gravel Pack ❑ Tracy Type of Casing. Iry C' Specifications <br /> M Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> C1 Irrigation -_._,Approx. pap h ❑ Eastern Surface Sedl Installed by <br /> Repair Work Done U Type of Pump Q H.P. State Work Done _ <br /> Wall Destruction 11 Well Diameter Sealing Material & Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUC ION CJ lNo septic system permitted if public sewer is <br /> available within'200 feet.l <br /> Installation will serve: Residence..,..... Commercial ther Q <br /> Number of living units: Number of bedrooms <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: Wellndation Property Line <br /> LEACHING LINE CI No. & Length of lines Total length/site n <br /> FILTER'BED n Distance to nearest: W Foundatio Property Line <br /> SEEPAGE PITS I I Depth Size Number r <br /> SUMPS L1 Distance to nearest: Weil Foundation Property Line <br /> DISPOSAL PONDS 0 <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 canify 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." Contractors 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 est It for all required inspections. Complete drawing on reverse side'. <br /> R <br /> Signed X Title: _�-[c+�-z r� „ ,,,.,. Date: `-ox� 7 <br /> RTMENT USE ONLY rr { <br /> Application Accepted by Date +ter Area + <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES"` _ <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201FEE \ <br /> CKO <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. ` <br /> . EN i3.24 tREV,I/ <br /> En it 5.-(g <br /> M:�•le <br />