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APPLICATION FOR PER-BIT <br /> �S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ,,; fA <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> (Complete in Triplicl�eA) <br /> Application is hereby mads to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations Of San <br /> Joaquin County Public Health Services. <br /> r <br /> job Address P Ciry�J C1C Lot Site/Acreager io <br /> Owner's Name C-eo! ecA,C-I, _ Address _d Phone rE&'EZZ/ <br /> Contractors Cp+r Address License NoS1z Phone ` 's7/2 <br /> TU <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR Cl OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK 91—A SEWER LINES !DO` DISPOSAL FLD. VA.- PROP. LINE iOCLL* <br /> FOUNDATION r AGRICULTURE WELL ,4I/4 OTHER WELL LIA PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> N <br /> n Industrial 0 Open Bottom 0 Manteca Dis. of Well Excavation f0 4" Dia. of Well Casing <br /> .(Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing, PUC Specification: !3--14 a <br /> ❑ Public I:1 Other ❑ Delta Depth of Grout Seal 5Iv) F,__-L Type of Grout Com# �'}!� T <br /> CJ Irrigation Appfox, Depth ❑ Eastern Surface Seal Instatlad by f'►TC�N , <br /> Repair Work Dons D Typo of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material k Depth <br /> Depth Yiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION M DESTRUCTION G (No septic system permitted if public sewer is (J`1 <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil Jo a depth of 3 foot: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.Cl Method of Disposal <br /> Distance to nearest, Well Foundation property Line <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest; Well Foundation Property Lina <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Wolf Foundation Property Line <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 cenifies 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 subcontracting signature <br /> codifies the following:"I entity that in the performance of the work for which this permit i=issued,I shall employ persons subject to workman's componss• <br /> tlon laws of California.,, <br /> The applicant a call r i requir d inspections, Complete drawing on reverse side. <br /> Signed Title; Date: <br /> FOR DEPARTMENT USE ONLY <br /> Applicallon A /ptod by Date / r Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES �sd <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON. CA 135201 <br /> FEE <br /> INFO AMOUNT DVE AMOUNT REMITTED K AECEivED av DATE <br /> CASH PERMIT.NO, <br /> H <br /> t :r.2s.4.26 <br />