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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> "MIT EXPIRES I YEAR PROM DATE ISSU OCT Vj��i�jT!F�9 1!L. 0?�AL"�f! <br /> (Complete in Triplicate) _ <br /> Application is hereby mode to Sam Joaquin Count for IEI2 1!T/SERVi <br /> Fp q y permit to construct and/or install the work herein descriUla This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules amd Regulations of $an <br /> Joaquin County Public Health Services. <br /> .lob Address a &��, Citylw!L Lot Size/Acreage <br /> VVawner's Name t/K�C/ Address t �-�- Phone <br /> Contractor / g2� ess v Rcense No, Phone ` �� <br /> TYPE OF WELL/PUMP. NEW WELL ID WELL REPLACE ENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATIONSYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> tic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public I'1 Other <br /> De Depth of Grout Seat Type of Grout <br /> M Irrigation Approx. De th astern urface Seal Installed by <br /> Repair work Done U Type of Pump H.P. (. St or Do <br /> Well Destruction ❑ Well Diameterf Sealing Material i Depth <br /> Depth l Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADOITION 0 DESTRUCTION G (No septic system permitted if public sewer is <br /> F available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of $oil to a depth of 3 feat:; l Water table depth <br /> SEPTIC TANK .. ❑ Typa/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> 0 <br /> Distance to nearest: Well Foundation Property Line <br /> a1 <br /> LEACHING LINE ❑ No. A Length of lines _ Total length/size <br /> FILTER BEd n ' Distance to nearest: TWell Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS +1 t 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 canities the following: "I ceriify that in the performance of the work for which this permit is issued, I shall not <br /> I 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 /> E Cerlifies the following: "I cenify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> L The app' an t call fo I equir inspections. Complete drawing on rove <br /> Sign dTitle: Date: `lT/ <br /> DEPARTMENT USE ONLY 7 <br /> Application Accepted by Date Area �T / <br /> Pit or Grout inspection by <br /> Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES T <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P d BOX 2009, STOCKTON, CA 95201 <br /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 1y71 tREY.I/K51 t� <br />