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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -5.0 <br /> ENVIRONMENTAL HEALTH DIVISION � I' <br /> P 0 BOX 2009, STOCKTON, CA 915201 <br /> { (209) 468-3447 <br /> - _DAJE ISSUEDR <br /> f (Complete in Triplicate) <br /> Application In hereby tttade,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> 1 application is made in cowliance 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 z3 I City Lot Size/Acreage <br /> E Owner's Name cs� Address W Phone i 11 <br /> Contractor. VX Address a RLicense Norm a-�f Plion77 <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ Monitoring Well �� <br /> SYSTEM REPAIR OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK'_ SEWER LINES DISPOSAL FLO. PROP, LINE=;2456 I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS/=LO r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom E) Manteca Dia, of Well Excavation Dia. of Well Casing <br /> LJ Domestic/Private C1 Gravei Pack 13 Tracy Type of Casing Specifications <br /> 0 Public fa Other ❑ Della', Depth of Grout Seal Typo of Grout <br /> t� <br /> CJ IrnUauon' —..Approx. Depth ❑ Eastern <br /> ,,/ PSurface Saul Installed by <br /> Repair Work Done J Type of Pump �`"'�'�""^--H.P. State Wor one ._ P <br /> Wait Destruction Well Diameter �[s � r Sealing Material 4 Depth v d M U (J <br /> Depth S r g. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION Ot INo septic system permitted if public sewer is <br /> available within 200 loot.) <br /> Installation*11 serve: L Residence— Commercial— Other <br /> Number of living units: Number of bedrooms I <br /> Character of soil to a depth of 3 feet: Water table depth i <br /> SEPTIC.TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Len fth of lines i <br /> g Total length/size, <br /> FILTER BED ❑ Distance —td—nearest:, Well Foundation Property Line <br /> ti <br /> SEEPAGE PITS 11 Depth Sire '1 Number ` <br /> SUMPS LI Distance to nearest; Weil "Fonu dation Property Line r <br /> DISPOSAL PONDS ❑ -'_ . - - r <br /> I hereby conify 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 wurkmsn'scompensation laws of California:':Contractor's hiring:or sub-contracting signature ] <br /> certifies the following: "1 certify that in the performance of the work for which this permit is loomed, 1 shall employ persons subject to workman's tompenoa• ! <br /> tion laws of California." I - t <br /> The applicant m at Cali r all required ins g r <br /> eq pection$, Complete drawing on reverse side. <br /> Signs A- <br /> A- CQ12S <br /> Title: �L Date: �3 <br /> FOR DEPARTMENT USE ONLY } <br /> \Oplicalion Accepted by I "'�^n- � _- "Date_ Area <br /> Pit or Grout Inspection by DateFina! Inspection by <br /> "`T' Dots ,21- <br /> Additional Comments: (_G� <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC ALTA SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERIEIT/SERVICES <br /> 445 N SAN JOAQUIN, P O SOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITIED CK <br /> CASH RECEIVED aY DATE PEAM17 N0. <br /> O <br /> • EH 17.24IREV. /M 6J .06 0 <br /> EH U-26 9I 91_ <br />