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,t APPLICATION FOR PERM I T <br /> 0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES (Y)ENVIRONMENTAL HEALTH DIVISION <br /> p 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> Y <br /> (Complete in 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 made in cemplianci with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Lot Size/Acreage <br /> Job Address q.. —n y <br /> :✓ _I/ ��_ Address`)� , lcJ Q-�a``<� d.C Phone 33 3— �e <br /> Owner's Name S <br /> Contractor <br /> Address License Nd63 Phone <br /> T <br /> TYPE OF WELL/PUMP: NEW WELL Q' WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of <br /> well 11 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O ,,AA <br /> DISPOSAL FLD. �' PROP. LINE,20 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS <br /> FOUNDATION 1 -^ <br /> - — AGRICULTURE WELL OTHER WELL p 0 <br /> G <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Bottom ❑ Manteca Die. of Well Ex / t( <br /> D Open Bocava n Dia. of Wel!_Casing V <br /> f_7 Industria! iM <br /> ' Specifications <br /> L<'DomesticIprivate a'Gravel Pack ❑ Tracy Type of Casing <br /> M Public Cl Other ❑ Delta Depth-of Grout Seal OC) — Type of Grout <br /> - <br /> a Approx Depili`'❑'Eastern` u ac• aUllns`talied <br /> CI Irrigation t <br /> Repair Work Done CJ Type of Pump s H.P. State Work Done <br /> Well Destruction ❑ Well Diameter 1 <br /> + Sealing Material i Depth <br /> _ Depth -A, Filler Mate,'trial i Depth <br /> TYPE OF.SEPTIC WORK: NEW INSTALLATION 0 REPAIR/AODITIONI0 DESTRUCTION G (No septic system permitted if public sewer is <br /> f avaiiable 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 feet: Water table depth <br /> SEPTIC TANK Type/Mfg { Capacity. No. Compartments <br /> Method of Disposal <br /> PKG, TREATMENT PLT, 0 ! —-------- <br /> .----�-�� <br /> Distance to nearest: Well Y Foundation Property Line <br /> LEACHING LINE C1No. & Length of lines _^ Total length/size <br /> k FILTER BED LI Distance to nearest: Well Foundation Property Line <br /> f SEEPAGE PITS„ r L l•.'Depth ik t Size Number <br /> `St1MPS LI�Disian s o nearest;wWelE Foundation —Property Line <br /> DISPOSAL PONDS ❑ . �I : <br /> i 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 I`te performance <br /> become subject to workman's compensalion laws of California." Contractor's hiring or sub contracting,signature <br /> canities the following: "I certify that in therformance of the work for which this_psrmi,t is isaued,_l ehal!_am <br /> fploy_persons.subjectio_wockrnans-compeasa-�. <br /> -_ �.- _= -r r----_ <br /> tion laws oCali `mIs. . <br /> The applicant cm <br /> 11 for alt irad inspections. Completes drawing on reverse side. <br /> I Signed <br /> iue: Date: <br /> h Ii <br /> I�. FOR DEPARTMENT USE ONLY <br /> Application Accepted by 4 Date Area <br /> Grou Inspection by Date Final Inspection by Date <br /> Pit o <br /> + I <br /> r Additional Comments: <br /> it ,U1� �,e/.t- �v �•. <br /> Applicant.- Return all copies to: SAN JOAQUIN COUNTY.PUBLIC HEALTH SBRVICEB <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO ' f�Xr (70 <br /> EH13-2,1IREv."n5) <br /> EH"bad s:r�-• <br />