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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 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 eoarpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> Job Address .. ` =r'T� � `�'��1� - City <br /> L.01>1_ Lot size/Acreage <br /> , <br /> Owner's Name (2i I Ct�nlr,010)L-- Address _q LgI <br /> Phone I <br /> Conlractor ddfe� T License No AWUPhon <br /> TYPE OF WELL/PUMP: NEW WELLS ELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Well O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O Monitoring Well OTHER ❑ e <br /> DISTANCE TO NEAREST: SEPTIC TANK NP SEWER LINES Q_ _aY._ DISPOSAL FLD.N9- PROP. LINE .1C_ <br /> FOUNDATION AGRICULTURE WELL _JLA_ OTHER WELL_ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial C3 Open Bottom O Manteca Dia. of Well ExcavationJ;eDia. of Well Casing <br /> Oamestic/PrivateGravel Pack 0 Tracy Type of CasingIn PVC Specifications <br /> 0 Public I:1 Other O Delta Depth of Grout Seal �g s _ Type of Grout I�s?tT ed Fs01ij <br /> 0 Irrigation _.Approx. Depth 0 Eastern Surface Seal Installed by CST u7 ,rn� lLtuil 1109 h�S -- <br /> Repair Work Done U Type of Pump H.P, State Work Dona_ <br /> Weil Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material IF Depth O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial.-._ Other <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 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal (� <br /> Distance to nearest: Well Foundation Property Line ''Ik <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/site <br /> FILTER BED ll Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O ^ <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 lC,\ <br /> rules and regulations of the Sen 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, t shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa. <br /> tlon laws of California." <br /> The epplic must call for all r wired inspeclions. omplete drawing on reverse side. <br /> ti <br /> Signed rlm 41 Title: _ pets: <br /> �.�..�� FOR DEPARTMENT USE ONLY <br /> Application Accepted by �--<• pate �-�I � �y _ Area j <br /> Pit orsou inspection by Date yam' Final Inspection by Data f <br /> Additional Comments. <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED X RECEIVED BY DATE PERMIT'NO. <br /> EH EMt'. t11[V.irper o0 307 <br />