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' APPL I CATV ON 'FCR PERM I T <br />' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, _,PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> it <br />! <br /> PERMIT EXPIRES I YEAR <br /> FROM DATE <br /> (Complete in Triplicate) <br /> Application is hereby made to Sea Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in ceupliance�with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin Count7jubl,ic Health Servics <br /> _.. <br /> Job Address - City Lot Size/Acreage <br /> 0 ner's Nam2Ad�t&/2 dressLAA_ Phone <br /> r <br /> i X/,+/ <br /> n o ,.C/1F License No. Z Phone <br /> TYPE OF WELL/PUMP: NEW WE WELL REPLACEMENT,47.1 DESTRUCTION 0 Out of Service Well ❑ <br /> - =PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK % r SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION ' AGRICULTURE LL OTHER WELL" PITS/ <br /> WESUMPS <br /> ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ustrial 0 Open Bottom 0 Manteca Dia. of Well Excavation- Dia. of Well Casing ' <br /> mastic/Private Cl Gravel Pack! ❑ Tracy Type of Casing_ - Specifications <br /> f ) Public 1.1 Other Cl Delta Depth'of Grout Seat <br /> 4IF Type ofrout <br /> t I i Irrigation —.Approx. Dept I i Epitern �urfaco Seal Installed by <br /> Repair Work Done 0 Type of Pum I H.P. State Work <br /> Well Destruction O Well Diameter Sealing Naterial i Depth l y g <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION f I REPAIR/ADDITION PDESTRUCTION I i lNo septic system permitted if public sewer is <br /> II available within 200 feet.) <br /> Installation will serve: ;Residence T Commercial_ Other <br /> Number of living units: Y " Number <br /> Character of soil to a depth of 3.fWtNar table depth <br /> SEPTIC TANK ❑ Type/Mfg' Y r Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ <br /> Method of Disposal <br /> # <br /> Milani' neared Well - Foundation Property Line <br /> LEACHING LINE C71 No t Length of lines Total length/size" <br /> FILTER BED ❑ Distance to nearest: a =Well Foundation r Property Line ` <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS C1 Distance to neareir. Well Foundation Property Line <br /> DISPOSAL PONDS 0 " <br /> I hereby Certify that I have prepared this application and that the work will be.done in accordance with San Joaquin county ordinances, statelaws, en <br /> E rules and regulations of the San Joaquin County <br /> Home owner or licensed agent'ssignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not r' <br /> employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring oi•sub-contracting signator <br /> I certifies the following: "I certify that in the performance of the work for which this permit is issued,I shell employ persons subject to workman's compenssl <br /> Win laws of California" a <br /> The applic t t CLU red in coons. Complete drawing on re side. # <br /> A? <br /> ig Title: Date:? <br /> q <br /> F DEPARTMENT USE ONLY <br /> i <br /> Application Accepted by DateArea <br /> Pit or Grout Inspection by Date I�Final Inspection by4"�� <br /> Data r ! <br /> Additional Comments: <br /> Applicant —Return all copiesf tG: San Joaquin County Public Health Services f^- <br /> Environmental Health Permit/Services ' <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> f <br /> IFEE O ' AMOUNT DUE A AUNT REMITTED CK RECEIVED BY ATE PERM17"11i <br /> . EFS1121 iRE1l. <br /> EN 1624 <br />