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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YE ROM PM ISS]gEp <br /> (Complete in Triplicate) <br /> Application is hereby made tO Sao Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance no. 549 and 1$62 and the Rules end uL <br /> Joaquin County Public Health Services. pegtions of Banr� <br /> k1ob Address �`t S City 4 Lot Sine/Acreage <br /> V/Owner's Name ddress Phone <br /> Xxontracto( Address es License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> 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 /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack* ❑ Tracy Type of Casing_ Specifications <br /> I'] Publk: F1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIO (No—sap <br /> Itc system permitted if public sewer is <br /> 1available within 200 feet.! <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units-. Number of bedrooms' <br /> Character of loll to a depth of 3 foot: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg <br /> Capacity No, ComPaKmants <br /> PKG. TREATMENT PLT.Ll <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b 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: Wall Foundation Pro I <br /> DISPOSAL PONDS ❑ t�rtY Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and <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 /> certifiss the following:"I certify that in the performance of the work for which this permit is issued,I shall em to <br /> tion laws of Calif is." P Y Persons subject to workman's compensa- <br /> The applicant i ull fo required 1 tions. r drawing on reverse side. <br /> -J <br /> , Signed >L Title: Date: �>✓o �Z <br /> _ F R DEPARTMENT USE ONLY <br /> Application A cc pted by - 1 Dale2 <br /> res <br /> Pit or Grout Ins / <br /> ptctbn by Date Fina! Inspection by Date <br /> Additional Commems: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaqu Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEp <br /> INFO K RECEIVED PY DATV PERMIT'NO. <br />• EM 13-24 ptEV.i i 14 Id �� ' <br />