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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES S t <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 NQ1J0X/C4& <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DAZE IQSUED <br /> (Complete in Triplicate) <br /> Application is hereby rade to SanJoaquin County for a permit to construct and/or Install the work herein described. This <br /> E application is made in coatpllanceivith San Joaquin County Ordinance No. 549 and 1862 sad the Rules and Regulations of Ban <br /> Joaquin County Public Health—Service <br /> Job Address. `^" City Lot Size/Acreage <br /> Owner's Name Address ' Phone <br /> E _ <br /> ;6� <br /> Contractor ItIgess t�g <br /> nae No. [`� wPhone <br /> TYPE OF WELL/PU NEW ELL ❑ WELL REPLACEMENT O DESTRUCTION 0 Out o service well D <br /> PUMP STALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ nitoring Well ❑ <br /> h DISTANCE TO NEAREST: SEPTIC T K SEWER LINES DISPOSAL FLO.t P P. LINE <br /> FOUNOATIO AGRICULTURE WELL OTHER WELL r ITS/SUMPS <br /> If INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ <br /> C7 Industrial ❑ Open Bottom Manteca pia. of Well Excavation Oia. of Well Casing <br /> fl Domestic/Private ❑ Gravel Pack* L] racy Type of Casing_I i Specifications <br /> II VI Public i"1 Other � Fl De -�---� ^�-Depth-of-Grout_SeaL_ Type of Grout <br /> I I Irrigation _Approx. Depth t I Easle Surface Seal Installed <br /> Repair Work pone 0 Type of Pump{ H. State Work Done <br /> Well Destruction ❑ Well Diameter Be ng Material k 1 <br /> Depth a Mlle terial i pth t 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I i REPAIR/ADDITI I DESTRUCTION 1—septic system permitted if public Bawer is <br /> i available within 200 feet.) <br /> Installation will serve: Residence Commereist_ Other { <br /> Number of living units: Number of bedrooms <br /> Character of sob to a depth of 3 feet: ?' E Water table depth <br /> SEPTIC TANK. 0 Type/Mfg ) t Capacity j No.'Compartments <br /> PKG. TREATMENT PLT. 0 J.. Mithod of Disposal <br /> Distance tojnear Fo�da rty Line O <br /> LEACHING LINE ❑ No. 5 Len } of line nth/siz <br /> FILTER BED 0 Dist o nearest: 1 Fund 'on � �� roperty Lin <br /> work e4t� COM feted Or ins ec e� <br /> SEEPAGE PITS 1 1 pth f 15ir11:lEMr ,fl'.]Tdr i <br /> SUMPS C Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS © i <br /> I hereby certify th,4Whave prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and requistibno.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 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 mUJft calkl2f all r utrad ' . tions. Complete r ng o reverse side. <br /> Signed r Title: Dates <br /> FO I MT4V8T-0—NLY <br /> Application Accepted by CADate_�_f L c�- l�- res - d <br /> } <br /> Pit or Grout Inspection bb�y��,,,,�� Q� Date - Final Inspection by Date <br /> Additional Comments. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> # Environmental Health Permit/Services r <br /> ll 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> lFEE AMOyNT DUE AMOUNT REMITTED , CK RECEIVED 9Y 0 TE PERMIT'NO. <br /> + Eli13-24(REV. <br /> EH N•26 <br />