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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <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 co4liance with San Joaquin County Ordinance no. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> f City Lot 'Size/Acreage Q/� <br /> Owner's Name ��! i !�Address � r Phone � <br /> ContraUor ddress �� >�License No. J�Phone / <br /> TYPE OF WELL/PUMP: -----N?W—WELD: WELL REPLACEMENT � fi "' <br /> DESTRUCTION tut of Service Well ❑ <br /> PUMP INSTALLATION,, SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC.TANK <br /> Sl WER LINES -DI FLD, � PROP. LINE-�`t <br /> FOUNDATION - _t AGRICULTURE WELL �� OTHE LL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIQN SPECIFICATIONS <br /> In industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation � 4 <br /> Domestic/Private - Oil. of Weft Casing <br /> ,'Gravel Pack • ❑ Tracy Type of Casing `�T C <br /> Q Public ('7 Other ._ �; Specifications <br /> ❑ Delta Depth of Grout Seat 'Type of Grout G Irfipation t�pprOx. Depth ❑ Eastern <br /> Surface Saul Installed by'rr-� <br /> Repair Work Done U Type of Pump H.P. <br /> ` <br /> Wall Destruction O Well Diameter •- Sealing Material i Depth State Work Done_Depth ' Pilfer Material I4 Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION L, REPAIR/ADDITIODESTRUCTION CI {No septic system permInstallation will serve: Residence Commercial Otheravailable within 200 feetNumber of living unite; Number of bedroomsCharacter of toil to a depth of 3 feet; <br /> SEPTIC TANK. Water table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ - <br /> Distance to nearest: . Well Method of Disposal <br /> Foundation <br /> _ Property Line <br /> LEACHING LINE 0 No. 8 Length of lines , <br /> Total length/size <br /> FILTER BED <br /> i l Distance to nearest; Well FoundationT <br /> Property Line <br /> SEEPAGE PITS It Depth Size <br /> SUMPSLl Distance Number <br /> to nearest: Well-�_ Foundation <br /> DISPOSAL PONDS ❑ ------- Property Line <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 /> San- <br /> rules and regulations of the San Joaquin County <br /> 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 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 /> cerlifies the following: "I certify that in the Performance of the work for which this permit is issuedI shall employ <br /> tion laws of California." ,P p y persons subject to workman's compensa- <br /> tion <br /> appfica u re ed ' s. Complete drawing on rover side. <br /> Signed <br /> Date: <br /> FOR DEPARTMENT USE ON <br /> ApplMGru <br /> ccepted by /1� <br /> Date V l Area ! <br /> Pit napection by� tU�22- <br /> Date �U Final nspection by <br /> Date <br /> •,, <br /> Additional Comments; �— i}7 Y5 , <br /> Applicant - Return all copies to: y <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f / ^ <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES ,l.� � Cry ��rvy <br /> 945 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON. CA 05201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED 'K <br /> , CASH RECEIVED 6Y DATE PERMIT'NO. <br />. EN I3•I117SEV.iin5i ' :&� <br /> C D�sj'p o��b93 tiV <br /> FM <br /> " Z G' <br />