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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HE4LWVIC S <br /> ENVIRONMENTAL HEALTH D�V <br /> 445 N SAN JOAQUIN, PHONE (J0�� 3420 <br /> P 0 BOX 2009, STOCKTON, �A <br /> PERMIT EXPIRES I YEAR FRO <br /> (Complete in Txiplica#�q�lr# V <br /> Application is hereby vi de,to fto Joaquin County for a permit to construct and7sv le <br /> application is made in ct�liance with San Joaquin County Ordinance No. 549 and 1862 and t e <br /> Joaquin County Public Health <br /> Ser/vices. '��C <br /> Job Address �..�� a ,�T �S� City Lot 'ize/Acreage <br /> Owner's Name +- Address „��r/[/� Phone i�� J 46 <br /> Contractor Address / t/< W'G License ,fin ��Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION 0 Out of Service well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER 0 Monitoring well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> 17.1 Domestic/Private O Gravel Pack 0 Tracy Type of Casing_- Specifications <br /> VI Public 1'1 Other fl Delta Depth of Grout Seal � RAYNl - T <br /> t I Irritiation —Approx. Depth I i Eastern Surface Seal Installed by RrEGEIVE 1 <br /> Repair Work Done LJ Type of Pump H.P. State Work Done — <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth S&N jmQim COUNTY <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No se tis s <br /> availaswWR 1 <br /> Installation will serve: Residence Commercial X Other <br /> Number of living units: -kM Number of bedrooms�4(34 r / <br /> Character of soil to a depth of 3 feet: -- Water table depth ` <br /> SEPTIC TANK. Type/Mip C pacity �Ao. Compartments <br /> PKG, TREATMENT PLT.0 /,,�... Method of Disposal <br /> Distance to nearest: Well A4V Foundation P57_ Property Line ZaL <br /> LEACHING LINE 0 No. b Length of lines T tel length/size <br /> FtLTER�BEO . Distance t0 nearest: Well Fou ndation �SSProparty Line �`` <br /> Kf�� <br /> SEEPAGE PITS I I Depth Size Number . <br /> SUMPS Lt Distance to nearest: Well 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 /> Homo 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 tub-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 taws of CatHorr"." <br /> The applicant mu for all required tion ComRlvlo rowing on r ids. <br /> Signed Title: Date: <br /> .4 FOR DEPART T USE ONLY <br /> Application Accepted by (✓` Oat* Area Z <br /> Pit or Grout Inspection by Date Final Inspection by Date 1a <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Rox 2009, Stkn, CAS�TE <br /> 0/ti/,5 <br /> 7� NFD FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY J{P.EERMIT'NO, <br /> . EN11t.I11EV.,,e�, I ��1 ��a3 - i <br />