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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) 468-3447 <br /> R <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 co�iliance with San Joaquin County Ordinance No. 549 and 11362 and the Rules and Regulations of flan <br /> Joaquin County Public Health Services. <br /> Job Address r1) Syl,L)y f�C City tom- Lot bite/Acreage <br /> s' <br /> r I{.JC/L-C� <br /> Owner's Name �,�- Address if,j� Phone <br /> Con tractor� Mdressd 1fa�f�-- Jr�Q License No. 3 5r6 Z Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ f WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION [ SYSTEM REPAIR ❑ I'L OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES.. _ DISPOSAL FLD. PROP...LINE- - <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public v Cl Other �' ❑ Delta Depth of Grout Seal Type of Grout O <br /> G Irrigation _ ".Approx. Depth ❑ Eastern Surface_Seal Installed by �j r <br /> Repair Work Done U Type of Pump-- H,P.__ <br /> Wall Destruction O Wall Diameter Sealing Material i Depth <br /> Work Done.� � � l2L•uYN,r <br /> ea <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION J0 REPAIRlADDITION 0 DESTRUCTION CJ (No 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 <br /> PKG. TREATMENT PLT. C Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/sire <br /> FILTER BED ', n Oistance"to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation�- „_, Property_Line_- <br /> DISPOSAL PONDS fa <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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not M <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 /> certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> -Non laws of California." <br /> The applicant must call r al required inspections. Complete drawing on reverse side. <br /> Signed Title: ,? - _ <br /> � Date: ��1= <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by -10�/ ,} 410 <br /> _4v�( <br /> Dots Araa <br /> Pit or Grout Inspection by Date Final Inspection byDate s <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES R <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N•SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0, <br /> INFO �+ CASH <br /> • EN 1124IREV.iiwsf f r oT1 <br />