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APPLICATION FOR PERMIT /`f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION � <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> P,ENIT EXPIRES 1 YEAR ?R9tDATE ISSUED <br /> ('Complete is 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 trade in ccuplianceavith San Joaquin County Ordinance No, 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, <br /> Job Address -- City t Size/Acreage 72 /fid <br /> Owner's Name kuA4. Address _ Phone <br /> -� <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP. V NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well, ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 /> f_1 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> U Domestic/Private [I Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> IZJ Irrigation _.Approx"Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump H.P. State Work Done _ <br /> Welt Destruction O Well Diameter)11 Sealing Material i Depth <br /> Depth { Filler Material & Depth <br /> TYPE OF .SEPTIC WORK; NEW INSTALLATION O REPAIR/ADDITION L1 DESTRUCTION (No septic system permitted it public sewer is <br /> vailable within 200 feet.) {., <br /> Installation will serve: Residence ._ Commercial— Other 11� <br /> Number of living units: Number of bedrooms �J <br /> Character of Boit to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. Q i Method of Disposal <br /> Distance to;nearest: Well Foundation Property line <br /> 1 <br /> LEACHING LINE ❑ No. $ Length of lines Total length/size <br /> FILTER BED n Distance io{nearest: Well Foundation Property Lina <br /> a <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to++nearest: Wall Foundation Property Line <br /> DISPOSAL PONDS E) It' <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 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 /> tion laws of California." »a <br /> The applican Cali t r at inspections. Complete drawing on reverse side. <br /> Signs Title: Date: <br /> Z <br /> OR DEPARTfvtEN7 USE ONLY <br /> Application Accepted byDate...[ raa / <br /> Pit or Grout Inspection by F ate Final Inspection by Data ( e <br /> r <br /> Additional Comments: f <br /> Applicant - Return all copies to:' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES T <br /> 4445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE i <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PEAMIT'NO. <br /> • EM 13-741AEV.i/nye ' <br /> EH A <br /> ` -/Ci. <br /> �{•Za YYY l <br />