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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 f <br /> P O BOX 2009,, STOCKTON, CA 95201 s <br /> PERMIT EXPIRES 1 YgAR FROM DATE S s <br /> (Complete in Triplicate) <br /> 11, <br /> Application is hereby made to BJoaquin County for a permit to construct and/or install the Work herein described. This <br /> an <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. r Th W 2 t/ <br /> City Lot Size/Acreage <br /> Job Address <br /> Phone <br /> owner's Name 1 Address <br /> rww Phone <br /> Contractor <br /> 1/�� Address _�� � License IVo. <br /> TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring'well ❑ <br /> 1A PUMP INSTALLATION ❑ .. <br /> DISTANCE„TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL .�.�T OTHER WELL PITS/SUMPS <br /> INTENDED USE ' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> !7 Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation __ Dia. of Wetl`Casing <br /> • 7T-17 <br /> Tracy <br /> Cl Domestic/Private 04ravei Pack C] <br /> Type of Casing_ Specifications <br /> t <br /> I'i Public 1-71'0”( fl Delta Depth of Grout Seal Type of Grout -* K <br /> I I Irrigation Approx. Depth I I EasternSurface Seal installed by - <br /> Repair Work Done U Type of Pump H.P.' _ } J ` State Work Done <br /> Well Destruction ❑ Well Diameter Sealing 4lfaterial <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR I ADDITION fYy`DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) `e <br /> Installation will serve: "Residence Commercial_ `.-Other <br /> Number of living units: Number of bedrooms <br /> Character of Boit to a depth'of 3 feet: Water table depth <br /> SEPTIC TANK. 0 . ,Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ tMethod of Disposal <br /> Distance to nearest: Well Foundation Property Line <br />€ LEACHING LINE 0 !No. b Length of lines ��, �{ � Total length/size <br /> FILTER BED --❑ Distance to nearest: Well Foundation -- Property Line ' <br /> SEEPAGE PITS 11 Depth Size pNumber <br /> SUMPS LI Distance to nearest: . Well-�.�=-P FoundationProperty Line <br /> DISPOSAL PONDS ❑ ; <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 /> t Home 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 shell 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 compenss- <br /> tion laws of Callfornle." N <br /> 7 <br /> The applicant mu ail,requir tions. 6mplete drawing on reverse side. <br /> Signed NM f2 'Title: `�;t�iP fi%(y-.� - Date: z <br /> FOR DEPARTMENT USE ONLY <br /> Application Assented by \BION.JV, Date `� Area CI — <br /> p <br /> or Grout Inspection by Date ilial Inspection by - ( � Date ^ <br /> Additional Comments: <br /> fi Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT D E AMOUNT RE tTTED K ?REEIVE4 Y DATE PERMIT NO. <br /> INFO <br /> . ENiS'Is tt1EV.1/n ei � <br /> 1H 1f-2a <br />