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1 <br /> -APVLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION j <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR PROM DATE ISSUED <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 cm1pliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address go City Lot Size/Acreage <br /> Owner's Name Address _.._ �/____� _ Phone �Ca <br /> Contractor �S Addressf License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl Monitoring Well <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 CONSTRUCT16N SPECIFICATIONS <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ti Domesfic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> _M Public 1.1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ IrrigationApproK, Depth C) Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump 7 H.P. State Work Done <br /> Well Destruction Welt Diameter e,> Sealing Material i Depth 11.1:50a= JP,,E7 <br /> Depth Piller MAiterial i Depth Ay . �_ t I) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION J0 REPAIRIADOITION M DESTRUCTION C1 lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation wilt serve: Residence— Commercial— Other e <br /> Number of living units: Number of bedrooms Q <br /> Character of soil to a depth of 3 feet: _.__Water table depth <br /> SEPTIC TANK O Typo/Mfg Capacity No. Compartments i <br /> I <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size � <br /> FILTER BED (_I Distance to nearest: Well Foundation Property Line { <br /> SEEPAGE PITS 11 Depth Site Number <br /> SUMPS Ll 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 /> 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 compo sa—, <br /> tion lawn Of Cali} <br /> The epplican II r uira n Pe �Mpleveng on reverse '08'— <br /> Signed Z ��� �.... Date: <br /> F EPARTMENT USE ONLY <br /> Application Accepted by Date ► Area <br /> Pit or Grout Inspection by Date Final Inspection byZ d Date�rZ���� <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 2008, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED I . CASH SECEIVEO aY DATE PERMIT'NO. <br /> . EH 13 24 tREV.t�nei /� x+51 A_( <br /> �'J-1�-q 0 I'D~ "a,s 7 <br /> EH 7125 1iGC/ C70 4 <br />