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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 j <br /> R=1T EXPIRES 1 YEAH PM PATE ISSUTA <br /> (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 I <br /> application is made in costpliance 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 ..eel v� ` �� – City Lot Site/Acreage <br /> �l�.z� <br /> Owner's Name <br /> l�- Address r . Phone <br /> � ----- <br /> f <br /> 11 <br /> ContrContractor ddress License No.-rwg"8�� Phone <br /> TYPE Of WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO t of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Q <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specilications � <br /> M Public I'1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U� Type of Pump H,P. State Work Done�• <br /> Well Destruction �qV Well Diameter — Sealing Material i Depth <br /> Depth r Filler Material i Depth <br /> i <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION C1 INo septic system permitted if public sewer is <br /> available within 200 leat.l <br /> Installation will serve: Residence_ Commercial_•__. Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity---------. No. Compartments <br /> PKG, TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number r <br /> SUMPS LI Distance to nearest: Well Foundation Property Line i <br /> DISPOSAL PONDS 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 C, <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 at irad i2o mplete drawing on reverse ids- <br /> Signed Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area.�21 (/ <br /> Pit or Grout Inspection by Date Final inspection by Date <br /> �:--t`. <br /> Additional Comments: 1 =f 1f,. – – <br /> I <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 85201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. <br /> . EH 13.24 MEV.1/N 51 <br /> EH;416 <br />