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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)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YE R M DATE ISSM <br /> (Complete in Triplicate) <br /> y Application is hereby made to San Joaquin County for s permit to construct and/or install the work herein described. This <br /> application is made in cestyliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Srvi ea. <br /> f <br /> Job Address V' City Lot Size/Acreage <br /> is Nam Address ` 1 v" -- — L� Phone <br /> dress f License No. 0 ` Phone zv <br /> TYPE OF WELL/PUMP: NEW VArft ❑ WELL REPLA EMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATIO SYSTEMA REPAIR 0 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL' , PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 I ustrial ❑ Open Bottom --❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> y atic/Private C1 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> i'l Public "` ""'f n Other' Fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation I .Approx. Dept '`'I I ern rface Seal installed by <br /> M "Repair Work Done w 0 € Type of Pump H.P. State Work Do <br /> a� + ' (1 Sealing Material i Depth <br /> Well Destruction '❑+ Well Diamet1er <br /> _f>epth �� 7 r filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer.is <br /> available within 200 feet.) l <br /> Installation will serve'""Residence Commercial_ Other Q <br /> Number of living units:,� Number of bedrooms / <br /> Chwscfvi`of sail to a depth of$feet:( Water table depth <br /> ASEPTIC TANK r ❑' Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> [� Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. 3 Length of linea Total length/size <br /> FILTER BED 11 Distance to nearest: Well Foundation Property Line <br /> 1 <br /> SEEPAGE PITS I I Depth Size - Number.• F ^N ..w <br /> SUMPS .,LI—Distance to.nearest:a ,..Wall _ u�itlation "A'-�Rrape ty.LLine_,,,��_ <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 /> Home owner or licensed agent's signature canifies 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 /> certifies the following: " rtify 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 alif le.' " <br /> The applica uq tail fo It ins tions. Complete drawing on ra selside. y� <br /> k Sig Th1 Date: U <br /> k FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data Area ��°z/ <br /> iPit or Grout Inspection by Date Final Inspection by Dates <br /> Additional Comments: <br /> k <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 446 N San Joaquin, P O Box'2009, Stkn, CA 95201 <br /> CK 0 <br /> IF 0 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE eP�ER??MIT''N0. <br /> I . EhFtsu111Ev.,iMO1 � � <br /> EN 13. , IWC 3-524 O O <br />