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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH %&RVICTsS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PMIT EXPIRES I Y FRPM DATE ISSUED <br /> FILE CORY <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. -This <br /> application is trade in coWliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of,San <br /> Joaquin County Public Health Services. �] <br /> Job Address l�@—J City Lot Size/Acreage <br /> r <br /> r <br /> Owner's Name ress Phone <br /> Contractor Address License No. / Phone v`4 <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT IF] DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <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 /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �l Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications ' <br /> i'1 Public I'1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation --__.Approx. Depth I I Eastern Surface Seal Installed by � ry <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material g Depth <br /> Depth Tiller !Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available:.within 200 feet.) <br /> Installation will serve: Residence_L.__ Commercial Other ` <br /> Number of living units: __L_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water labia depth <br /> SEPTIC TANK. ❑ Type/Miy . � ` -- .— Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> Distance to nearest: Weil oa Foundation ' Property Line 212 <br /> LEACHING LINE Ll No. b Length of lines 3 Total length/size' <br /> FILTER BED Cl Distame to nearest. Wall er Foundation EVProperty Line QQ . <br /> SEEPAGE PITS I I Depth X f Size Number <br /> Ll Distance to nearest: Well�`-�``=-� Foundation_ Property Lin* 9 <br /> DISPOSAL PONDS ❑ <br /> I hereby c*rlify 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 /> Home owner or licensed apnt's signature certifies the following: "t certify that in the performance of the work for which this permit 15 issued. I shall 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 Iha following:"1 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 Californts." <br /> The applicant ust 11 for AM Had spuctions. C m to drawing on reverse side. �J <br /> gigue Title: Date: / <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 3 n Area L� <br /> Pk or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services .l\ <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 8 RECEIVED BY DATE PERMIT'NO. <br /> INFO ` CASH //��. <br /> . Elit3211REV.ti/N5ls!✓ �! �L��� 9� <br /> EH 14.96 r I // <br />