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APPLICATION FOR PERMIT ;.,� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC$3&- <br /> ENVIRONMENTAL HEALTH DIVISION a <br /> k P O BOX 2009, STOCKTON, CA 952 .lk <br /> (209) 468-3447 �/� 0y <br /> 3 <br /> pEgUIT EX]?IRES x YEAR P&A DATE- iSs �/ � r� ' vi <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install the Wok fipi�4 �srLLi,bed. This <br /> application is made in conpliance with.San Joaquin County Ordinance No. 549 and 1$62 and the Rules and .i;la als of San <br /> Joaquin County Public Health Services. <br /> Lot Site/Acreage <br /> Job Address Cit �} <br /> Ow is Nam a Address �'�-� Phone <br /> ff r (cense No. �f Phone <br /> on actor rens <br /> TYPE OF WELL/PUMP: NEW L ❑ WELL REPLACEM T 71 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIQ><* OTHER p Monitoring Well <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 /> n Industrial ❑ Open Bottom C] Manteca Dia, of Well Excavation Dia. of Well Casing <br /> ��mestic/Private ❑ Gravel Pack t n Tracy Type of Casing Specifications <br /> ID Public 1;1 Other € ❑ Delta Depth of Grout Seal Type of Grout <br /> G Irrigation ._.._..Approx. Depth 0 Eastern Surface Seal Installed by ` <br /> Repair Work Done U Type of Pump H.P. State Work D ?t <br /> Well Destruction O Well Diameter t Sealing Material i Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/AD.DJTIO.N_L7—QES.TRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feat.l <br /> Installation will serve: Residence.....,.. Commercial Other -` r �V- <br /> Number of living units: Number of bedrooms 1 <br /> Character of soil to a depth of 3 feet: t s Water table depth <br /> SEPTIC TANK: ❑ Type/Mfgt— — `Capacity No. Compartments \�1 <br /> PKG. TREATMENT PLT.G1 Il Method of Disposal <br /> Distance to nearest: Well AFoundation t- - Property Liris <br /> LEACHING LINE 0 No. & Length of lines. i Total length/size <br /> FILTER BED C-I Distance to nearest:' Well Foundation I _i6roperty Line <br /> �3 t <br /> SEEPAGE PITS 11 Depth Site Number <br /> SUMPS Ll Distance to nearerWell- �'.' — --Foundation-- Property Line <br /> DISPOSAL PONDS Ea <br /> I hereby certify that f have prepared this application and that the work will be done irraccordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cenifiei'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 becoMwsubject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the perfofmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of C • rnia." ` <br /> The applic t e►at calClorl_al� dins ions. Com ete drawing an side. <br /> r <br /> Sig ed Tit Date: <br /> OR DEPARTMENT USE ONLY <br /> gyp <br /> Application Accepted by Date Area _ 211 <br /> Pit or Grout Inspection by I Date Final Inspection by Date <br /> Additional Comments: { <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 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 0 HiCEiVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> . EH 17.21 IR[N.I IF,yi ^Y <br /> EH;1•ab <br />