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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)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I XBAR FROM DATE IS9JJZED <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin, County Public Health Servicea. <br /> �p� 7 3 _ �� � _ ��Cit Lot Size/Acreage <br /> ob Address ... <br /> 'LOwnet'sName57 <br /> Address 9PhoneAddress " � LicensePhonr <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT I.] "N DESTRUCTI t of Service Well ❑ <br /> PUMP INSTALLATION D SYSTEM REPAIR L3OTHER Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL•FLD. PROP. LINE <br /> FOUNDATION r AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial D Open Bottom 0 Manteca `";� Dia. of Well Excavation Dia. of Well Casing A <br /> [I DomesticlPrivate ❑ Gravel Pack 0 Tracy `' Type of Casing Specifications <br /> I'I Public Cl Other 11 Delta Depth of Grout Sea[ Type of Grout <br /> I I Irrigation ___Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> E OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is <br /> available within 280 feet.! <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of Boit to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK. D Type/Mfg f Capacity No. Compartments <br /> KG. TREATMENT PLT.❑ Method of Disposal <br /> Distance t nearest: Well <br /> Foundation Property Line <br /> I <br /> LEACHING LINE D No. Length of lines Total length/size <br /> FILTER BED (D Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISP AL PONDS ❑ r <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 /> II 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 /> 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 /> tion laws of California." <br /> The applicant must 11 for all required inspect' s. Complete drawing on reverse lye. <br /> Irl /Signed Title: Date: <br /> i FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 3� - Area <br /> Pit or Grout inspection by Data Final Inspection by Date �✓ CJS <br /> Additional Comments: &X42= W <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services �h� <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 85201 �N <br /> FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY D TE PERMITN0. <br /> i INFO <br /> 13.24(REV.I/R 51 S / �Y . • /I J <br /> t Em t4.26 ` L 0 <br />