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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PAYNUE <br /> NT <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009,. STOCKTON, CA 95201 "'DIVED � <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEE1 <br /> (Complete in Triplicate) SAN JOAQUIN COUNTY <br /> Y <br /> PUB;-[C I• EALT�l SERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install Ei�l�'�n��i'rlteeLt�c� � rBedi+fThis <br /> application is made in coWliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San i <br /> Joaquin County Public Health Services. <br /> Job Address _- � __ _ City Lot Size/Acreage <br /> /tlQ•�a� <br /> Owner's Name Address L Phone <br /> Contractor�. - _ Address Oar 7 License No. -&� .-Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well D <br /> PUMP INSTALLATION $L SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> n Domestic/Private ❑ Gravel Pack D Tracy Type of Casing- Specifications <br /> 1�1 Public Cl Other fl 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 0 Type of Pump--i-N-ht H,P. --- _ State yVork Done <br /> Well C14tfuction © Well Diameter Sealing Material fi Depth, _ <br /> 4. Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I 1 DESTRUCTION I I !No septic system permitted if public sewer is <br /> �,,,� available within 200 feet.) <br /> Installation vi ll�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, Ll Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. fit Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation .Property Line - <br />'"-"'DISPOSAL'PONDS ❑-- e <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 fegulatiorts of the Sen Joaquin County <br /> Homs 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 compents- <br /> tion laws of California." <br /> The opplicantjpust call forall r Wad inspections. Complete drawing oAZ49-C-111 <br /> de. <br /> Signed Title: -_ _—-- Date:ZOU2 - <br /> DEP TME NLY <br /> Application Accepted by Date rea <br /> Pit or Grout Inspection by Date Final Inspection by Dats��� <br /> Additional Commants: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEf AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIVNO. <br /> INFO CASH <br /> . EN 13-24 IREV.+les 0 <br />