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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ' PERMIT EXPIRES I Y_F4R FROM DATE S <br /> _ L <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 compli cel with San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health e . <br /> lob Address/ City Lot Size/Acreage <br /> /' Owner's Name ddress Phone <br /> XContractor11wV Uf_f - Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION D Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR OTHER ❑ 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 /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications �] <br /> I'1 Public n Other n Delta Depth of Grout Seal Type of Grout p i� <br /> I I Irrigation -..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well"Diameter Sealing Material i Depth , <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I OESTRUCTION.i'I. (No,septicsystem permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence____ Commercial_ Other ` n <br /> Number of living units:� Number of bedrooms v ' <br /> Character of soli to a tMpth of 3 feet: Water table depth i <br /> SEPTIC TANK. ❑" Type/Mfg Capacity No. Compartments <br /> f KG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> t <br /> LEACHING LIME Cl No. 6 Length of lines <br /> Total <br /> e length/size <br /> FILTER BED 0 Distance to+clearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth p Sire Number <br /> SUMPS LI Distance to nearest. Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 v <br /> Home owner or licensed agent's signature-cenifies the following: "I,certity that in-the performance ofLthe work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to;work'man's compensation laws of California Contractor's hiring or sub-contracting signature <br /> certifies the following: "I unify that in the performance of the work for which this,permit is issued, I shall employ persons subject to workman's compensa- <br /> ftn laws of California.-''- <br /> The a nt must 11 for all uir i pe.ctions. Complete-drawing,$rlyeve ss side, <br /> Signed r Title:CC��ff!!�n w A, CJ <br /> tt Date: <br /> (� f OR EPARTMENT USE ONLY a. <br /> Application Accepted by —_�AY ' an� � � �R,a - Date <br /> Pit or Grout Inspection by Date Final Inspection <br /> Additional Comments: 4 <br /> t . <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 /> # IF EE Q AMOUNT DUE AMOUNT REM}TTED CASH RECEIVED BY DATE PERMIT'NO. <br /> a.EM 13-24 trtEV.1/AS1 ^}+ r+. +q 9 3-03 <br /> EH 11-26 rr <br />