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APPLICATION FOR PERMIT <br /> i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I PERMIT EXPIRES I YEAR FROM DATE 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 1$62 and the Rules and Regulations of San <br /> Joaquin county Pub c Health Services. <br /> ' Job Address <br /> n City Lot Size/Acreage <br /> w is Name dress <br /> o Tactor r �l/31-32 <br /> r s ne <br /> is nae No. / pho <br /> TYPE Of WELL/PUMP: NEW WE WELL REPLACEMENT F1 DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR EIOTHER O Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _.. <br /> I <br /> INTENDED.USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial:.❑_Open.Bottom_4 _C7.Mantec � Dia. of Well Excavation Dia. of Well Casing <br /> astic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> A'] Public I:1 Other n Delta Depth of Grout Seal Type of Grout <br /> 1 I Irrigation Approx. Dept I I astern Surface'Seal Installed by c 1 <br /> E Repair Work Done L] Type of Pump H. State Work D Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> l <br /> Depth biller Material i Depth <br /> :TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION F . DESTRUCTION I 1 iNo septic system permitted it public sewer is <br /> `:: available within 200 feet.) <br /> i <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. ❑ Method of Disposal f <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size f <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> -SEEPAGE PITS 11 Depth Size ` Number <br /> I SUMPS CI Distance to nearest: Wall Foundation Property Lina <br /> DISPOSAL PONDS ❑ a - / <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 regulations of the San Joaquin-County <br /> Homs owner or licensed•agen't s�gnalure_certifies_the-fotlowing: "I certify that in the performance of the work for which this permit is issued. I shall not <br /> k employ any person in:sueh manner as to-become subject to-workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 'M certifies tthe following: "I certify hat 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 ornis."`- �,� i <br /> The applies t call for I r i ed ins tions. Completeifrawing an raver ids. <br /> f <br /> Sig v Title:: Date: <br /> ` OR DEPARTMENT USE ONLY <br /> Application Accepted byr4.ns�� � = z DatadZ \ 1 <br /> Area <br /> Pit or Grout Inspection by v Date Final Inspection by Data <br /> Additional Comments: <br /> I Applicant - Return all copies to: - San Joaquin County Publid�Health Services <br /> Environmental Health Permit%Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 l <br /> INFOIFEE AMOUNT DUE AMOUNT REMITTED CASH '' � RECEIVED BV DATE PERMIY'NO. <br /> CK <br /> a EH 1171 tItEV.�/R 5PIP1 <br /> FN 1 ^ <br /> ` 12E • 0 <br /> .r <br />