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i '. APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES I R ?ROM DATE ISSIZIM <br /> (Complete in Triplicate) <br /> Application In hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in 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 /> _ I <br /> Job Address _{1_,(_2 Size/Acreage <br /> Owner's Name lLAQ- - �� __ Address` �- � � Phone <br /> ( s j {v <br /> ContractorAddress a2. License N �Phone / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service tell Gl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR " OTHER O Monitoring Well <br /> DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPOSAL`FLD. PROP. LINE w :l <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f-1 industrial D Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> ,'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> C3 IrriOauon —.Approx. Depth b Eastern Surface Seal Installed by <br /> Repair Work Done >16— Type of Pumper H.P. :�- „ State Work Donees <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIRIADDITION M DESTRUCTION G (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence__'_. Comm cial Other ' <br /> Number of living units: Number of bedrooms. " <br /> (1 Character of soil to a depth of 3 feet: >F l F Water table depth } v <br /> �•}? SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 _ �'""'"� --� _ Method of Disposal r <br /> Distance to nearest: Well Foundation Property Lins <br /> T <br /> LEACHING LINE Cl No. & Length of lines Total length/size + <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest; Well Foundation Property Line <br /> DISPOSAL PONDS a 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 cenifies 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 compensations laws of California." Contractor's hiring or sub-contracting signature <br /> cenifies 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 mu r all requrued inspections. Complete drawing on reverse side. <br /> SignedTitl - - — Date: � '�f f <br /> __ <br /> FOR DEPARTMENT USE ONLY <br /> �.. :• a <br /> Application Accepted by Date ECAE <br /> Pit or Grout Inspection by Date Final Inspectio y !' n <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 BOR 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT R <br /> EMITTED 'CgSH � RECEIVED BY DATE PERMIT NO, <br /> EH13.24 4REV.I i n Cil <br />