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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) 468-3 �134-10 <br /> P�RI[IT EXPIRES 1 YEAR FROM RATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby made to San Joaquin County for s 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 Services. <br /> XJobAddress �3 V� 'I✓ City _�T(�G /�+'� Lot SiZe/Acreage 1t3o� 7'� <br /> � <br /> A l <br /> Owner's Name 5Address AAL f Phone "0� <br /> 1( Contractor Address incense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out oSAarvice well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER onitoring Well <br /> DISTANCE TO NEAREST: SE NK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHE L PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE CON STRUCTI ECIFICATIONS <br /> fl industrial ❑ Open Bottom ❑ Manteca sit Excavation Dia. of Weil Casing <br /> U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casin Specifications <br /> R Public 1-1 Other a Depth of Grout Seat Type of Grout �\ <br /> G irrigation Approx. ❑ Eastern Surface Sou! Installed by <br /> Repair Work Done ❑ T ump H.P. State Work Done_ <br /> Well Destruction Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION L7 DESTRUCTION INo 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 ❑ Type/Mfg Capacity No. Compartments 3 <br /> PKG. TREATMENT PLT, 0 Method of Disposal c,Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED n 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 ❑ <br /> 1 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 /> canities the following: "I certify that in the performance of tMe work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California.' <br /> The applicant mu ca jr (equired i Complete drawing on reverse side. / <br /> kSigne Title• " Data: . �- <br /> 1 / <br /> FOR EP RTMENT USE ONLY <br /> C <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by - Date � <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 85201 <br /> FEE <br /> INFO AMOOUNT DUE AMOUNfT]REMITTED CASH <br /> w ` <br /> RECEIVED BY DATE 11 PERMIT NO. <br /> • EN 13.24 01 EV.1) <br /> 5) 141DO <br /> a I v� <br /> EH t1•?e I `yL l I + <br /> A <br />