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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) 468-34147 - <br /> (Complete <br /> 68-3447(Complete in Triplicate) <br /> Application is hereby made to San 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 and Regulations of San <br /> Joaquin County Public Health Services. <br /> �: City Lot Size/Acreage <br /> e) <br /> KJob Address N �/ <br /> —�T., . Address �� Phonefiv� <br /> L/Own <br /> Name �,�. <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELLIPUMP. NEW WELL D WELL REPLACEM T D DESTRUCTION CT Out of Service We11 Ci <br /> PUMP INSTALLATION ❑ f SYSTEM R AIR C1 OTHER <br /> Monitoring Well <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER lIN S <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTU WE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL� EM AREA C RUCTION SPECIFICATIONS pia of Well Casing <br /> 0 Industrial D Open Bottom 0 Manteca � Die f Well Excavation Specifications <br /> U Domestic/Private Cl Gravel Pack C] Tracy l T pe f Casing <br /> � Public Cl Other I D Delta # <br /> epth Grout Seal Type of Grout <br /> Approx. Depth Eastern i Surface ajl Installed by \ <br /> GI Irrigation - <br /> Repair Work Done L3 Type of Pump H.P, State Work Done <br /> Well Destruction © Well Diameter.. <br /> Se ittg Material Depth <br /> Depth E liar Material i th <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L7 REPAIR/ADDITION 0DESTRUCTION available septic <br /> system <br /> feet.) <br /> led if public sewer is <br /> Installation will serve: Residence�� Commercial— Other <br /> Number of living units: Number of bedrooms 3 <br /> Character of &oil to a depth of 3 feet; f Water table depth <br /> SEPTIC TANK © Type/Mfg 4 Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ ; <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total langth/size <br /> t FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> 1 <br /> SEEPAGE PITS Il Depth I Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this'appl;cation and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of the Sen 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 /> E 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 must tali for all required inspection Complete drawing on reverse side. <br /> Signed Title: Date: (� <br /> FOR PARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date!'-', Final inspection b <br /> Date —___z _1?/ <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 O BOX 2009, STOCKTON. CA 95261 <br /> FEE CK RECEIVED BY DATE PERMIT NO, <br /> MOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> 00 ��� - la- I d 3-- <br /> EH 13-24 4IIEV.,/�+si �r� <br /> EH,4,� V <br /> 4 <br />