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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HBALTR DIVISION <br /> + P O BOX 2009, STOCKTON, CA 95201 , <br /> 4,ti►'�� 0,c (209) 466-3447 <br /> I <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to eonstruet and/or install the vork herein described. This <br /> application is made in compliance with San Joaquin County ordinance no. 549 and 2 and the Rules and Regulations of San <br /> Joaquin county Public Health Service <br /> City ,, <br /> Job Address <br /> r Lot lilac/Acreage ' <br /> e� 1 <br /> Owners Name Y �'�- Addrass Phone (� <br />� <br /> Addres 8 license No Phone`Contractorw ' <br /> i TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT 11 DESTRUCTION ❑ Out MO <br /> caietoring WellPUMP INSTALLATION El SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENtEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom D Manteca Dia, of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 1:1 Other ❑ Delta Depth of Grout Seal Typo at Grout <br /> G Irrigation Approx, Dep Eastern Surface Seal Installed by <br /> Repair Work Done QK Type of Pump .. ctje H.P, .1 - State Work Oa. <br /> Wall Destruction O Well Diameter Sealing Material i Deptb <br /> Depth Piller Material i Depth "V <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATION❑ AE PAIR IADDITION 0 DESTRUCTION G INo septic system permitted if public sewer is r� <br /> t available within 200 feet,l V 1 <br /> Installatign w9l serve: Residence_ Commercial_ Other t <br /> t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK *•O TypelMfg Capacity Pic. Cornpartme`tsj r <br /> PKG. TREATMENT PLT,CI Method of Disposal \� <br /> Dislance to nearest: Well Foundation" Property Line <br /> I LEACHING LINE L'1 No. 6 Length of lines Total iength/size.- <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE'fiTS I I Depth Site Number <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 177 <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 Sen Joaquin County <br /> Home owner or licensed agent's signature canities the following: '9 certify that in the performance of the work for which this permit is issued. I shalt not <br /> } employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> eertifiss the following: "I certify that in the performance of the work for which this permit is issued, I shall employ perimns subject to workman's comps a- <br /> tion laws of California." I' <br /> The applic s all for alt required C Co ate drawing on r side. Y ��_ ) <br /> Signed c Title: _._f "r. ._ ._ - -- Date: LZ'17 <br /> ZFOI�pAR.TMENT USE ON_LY�� q <br /> I Application Accepted by ._Ll ' VDole ,3`-� i� `0 Area <br /> Pit or Grout Inspection by Gate Final Inspection by <br /> Date <br /> Additional Comments: <br /> Applicant - Return all copies to SAN JOAQUIN COUNTY PUBLIC HEALTH $911VICBS <br /> i ENVIRONME1TAL HEALTH DIVISION POMIT/SERVICES <br /> 448:N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 86201 <br /> FEE <br /> INFO DUE AINOUNT REMITTED CASH RECEIVED BY DATE PERMP'NO. <br /> INFO <br /> -3af�3 4 <br />