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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 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) i <br /> Application is hereby made-to San Joaquin County for a permit to construct and/or install the work herein described. This I <br /> application is made in eaaplinnce with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot,Size/Acreage <br /> Owner's Name Address .� -_ Phone <br /> Contractor <br /> Address License No.,305 2AI Phone G <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> F1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> V] Public 1:3 Other Fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I 1 Eastern Surface Soul Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION l I Wo septic system permitted if public sewer is <br /> 1 available�hinfeet.) <br /> Installation will serve: Residence— Commercial- Other . <br /> Number of living units: Number of bedrooms <br /> Character of loll to a depth of 3 feet: A1014 Water table depth <br /> SEPTIC TANK. C41­Type/Mfg ¢L Capacity-26QU No. Compartments- <br /> PKG. TREATMENT PLT.CI Method of Disposal <br /> Distance to nearest: Wel Foundation 492Q Property Line P <br /> LEACHING LINE L4-No. 6 Length of lines ��7 1 Total length/size F49 <br /> FILTER BED ❑ Distance to nearest: Well&/ Foundation Property Line <br /> SEEPAGE PITS IC�- Depth �?T ' -Size / 9 <br /> ���, Number , <br /> SUMPS CI Distance to nearest: Wall_AQ01_� Foundation /Od' 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 requi ins ctions. Complete drawing on reverse side. <br /> Signed _ Title: Data: <br /> FOR DEPARTMENT USE ONLY , <br /> Application Accepted by r X date ;) 2 2 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 1j <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services M, <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 k _ <br /> INF AMOUNT DUE AMOUNT ftEMITTEO CASH _ RECEIVED BY DAT PERMIT'NO. <br /> • EM 13.21fREY.I/115! '/ / /�� <br /> EM 11•m ! S./ / <br />