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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) 468-344-7 3goo <br /> PERMIT EXPIRES 1 YEAR eROM DA19 ISSUES <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 <br /> application is made in eotstipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> Job Address g City Lot Size/Acreage <br /> Owner's Name # ddress Phos <br /> �,,,, <br /> Contractor Address — License No. L�--� Phone <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLAC MENT ❑ DESTRUCTION 0 Out of Service well L1 <br /> PUMP INSTALLATION 0 - SYSTEM REPAIR E) OTHER C Monitoring Well C.3 <br /> r <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PtTS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f7 Industrial ❑ Open Bottom j❑ Manteca Dia. 01 Will Excavation""' -" "Dia of Well Casing` <br /> i <br /> LJ Domestic/Private <br /> 0 Gravel Pack wn Tracy Type of Geeing Specifications <br /> M Public ("1 Other ❑ Delta It Depth of Grout Seal Type of Grout <br /> 0 If } w.Approx. Depth 0 Eastern Surface Seal Installed by <br /> -Repair Work Dona U Type of Pump # H.P. State Work Done `r <br /> "+r Well Destruction O Well Diameter Sealing Material 4 Depth <br /> i <br /> r Depth Piller Material i Depth <br /> TYPE OF.SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION IN DESTRUCTION F-I lNo septic system permitted if public sewer is <br /> y r iel • I I available within 200 feet.) +. <br /> Installation will serve:., Residence _ Commercial_..,,. Other <br /> /Number of diving ".units: 4?..! "Number of bedrooms <br /> `Character of-s61l,lo a depth-of 3 feet: :tk � Water table depth <br /> lir-SEPTIC,TANK'/,1, ❑ Type/Mfg f Capacity No. Compartments <br />'I PKG. TREATMENT,PLT, ❑ �p ��' _ _ �» � Method of Dit;posal <br /> - Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE 11 No. & Length of lines Total length/size <br /> I� <br /> FILTER BED Cl Distance to nearest: Well W Foundation ¢w yam. Property Line <br /> SEEPAGE PITS $6 Depth 2� SizeI ' )Numbers... <br /> SUMPS Ll Distance to nearest: N oundstion,. "�WPropeity LirSa '-� <br /> DISPOSAL PONDS ❑ l <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, an <br /> rules and regulations of the San Joaquin County 1 r""` t ? <br /> i Home owner or licensed agent's signature canities 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 Calilornia." Contractor's hiring of 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 must II for all required inspections. Complete drawing on reverse side. <br /> Signed X Tide: - � Date: <br /> E r t. <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by r _ ~Date �� Ai a <br /> Pit �Grout Inspection by Y Date Final Inspection byz Date rL� <br /> i Additional Comments. 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 BOX 2049, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> . EH 13.24 IREV.i r n sm <br /> EH ;{•le <br />