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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 .EXPIRES 1 YEAR PBQX PATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby mLde,to San Joaquin County for a permit to construct and/or Install the work herein described. Thio <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules Lind Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> g_ <br /> Owner's Name ' ���� - �-�� Address Phone 21k IF <br /> ContractorAddresses /r�� A�.44f1�� License No. �,� Phone <br /> TYPE OF WELL/PUMP: NIEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION t of Service Well C) <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 /> f71 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> U Domestic/Private . _ _0.13ravel Pack _.❑ Tracy x. -,Type-of Casing - Specifications <br /> M Public ' � Cl Other O Delta Depth of Grout Seal Type of Grout <br /> G Iriiga+Ian _.Approx. Depth ❑ EasternSurface Seal Installed by <br /> Repair Work Done U T p <br /> P Yf�of Pum � H.P. State Work Dor ��1J1 <br /> Sealing Material Z Depth J <br /> Well.Destruction Well Diameter _-_1�_ x& <br /> Depth._ Filler-Naterial"&7Depth �•�� f� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADOITION 0 DESTRUCTION M (No septic system permitted it public sewer is <br /> available within 200 feet.l /gip <br /> Installation will serve: Residence�__ Commercial— Other Zt . <br /> Number of living units: Number of bedrooms 'I <br /> Character of &oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 4 Distance to nearest: Well Foundation Property Line _ k <br /> f.. <br /> LEACHING LINE .:...Cl No. 8 Length of lines Total length/size i <br /> FILTER BED C'1 Distance to nearest:. Well foundation Propeny Line r <br /> SEEPAGE PITS [ I Depth Sire Number ►1 <br /> SUMPS LI Distance to nearest: Well Foundation Property Line rh--- <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 cenify that in the performance of the work for which this permit is issued, I shall no& <br /> employ any person in such manneras to become subject to workman's compenia lion"laws of California," Contractor's hiring or sub-contracting signature <br /> certifies the following: "I cenify thit in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion taws of Californlai." <br /> The applicant must o it d ins I mplete drawing on reverse e: T <br /> Signed Xtae: 0 Date: <br /> FOR DEPARTMENT USE ONL <br /> Application Accepted by ( e,._.,w�.� _ Date Area <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date Ix d <br /> Additional Comments: <br /> r <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 BO% 2008, STOCKTON, CA 85201 <br /> INFO FEEAMOVNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT M0. <br /> �7 <br /> I <br />