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APPLICAT10N FOR PERMIT <br /> j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT NWIfl& 1 -YEAR PROM PATE ISSUED <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 compliance, 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 t ify 2 City hot Site/Acreage <br /> Naddress`,. - _.. Phone r <br /> r f' <br /> Contras or Adtss itense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC MENT n DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring well [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> tic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public Cl Other 1 ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irrigation _Approx, <br /> 1�lf <br /> ern urfaee Seal Installed by <br /> Repair Work Done >< Type of PumpH.P. State Work DoneWelt Destruction ❑ Well DiameterSealing Material & Depth C /� <br /> Depth_L2L biller Material i Depth rV'ht <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feat.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, Cl f Method of Disposal <br /> Y <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE C1 No. & Length of lines _ Total length/sire <br /> FILTER BEDDistance to nearest v well Foundation Property Line 3 <br /> i <br /> SEEPAGE PITS I I Depth <br /> ---Size '"-� <br /> �- Number <br /> SUMPS LI Distance to'nearost: Well .,..Foundation` Pr m <br /> - Property Line <br /> DISPOSAL,PONDS .- ❑ „► ._. <br /> I hereby certify that I have prepared t iis,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 ticensed 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 parson in such manner as to become iubjact 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-. r " I <br /> The applicant call for�( i. in".clions. Complete drawing an raver side: <br /> 1' <br /> Signed Title: N.. � <br /> - -- Date: <br /> R DEPARTMENT USE ONLY _ <br /> Application Accepted by lILA 01Date_ Araa_ <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTALHEALTH DIVISION PERMIT/SERVICES ; <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOU DUE AMOUNT REMITTED tK RECEIVED 8V DATE PERMIT'NO. <br /> INFO CASH <br />