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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 /> YEAR <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 coerpliance with San Joaquin county ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City J Lot Size/Acreage <br /> Job Address } `� <br /> i(/i(l //� /� ---� Phone J <br /> t Owner's Name Q <br /> Contractor SS dress <br /> -��Q =cense No. All; _Phone ^— <br />' WELL REPLACEMENT DESTRUCTION ❑ Out of Service well G7 <br /> TYPE OF WELL/PUMP: NEW WELL: V OVER �i Monitoring Well [7 <br /> PUMP INSTAL I SYSTEM REPAIR C] _4'Rg1 .� � <br /> DISPOSAL FLD. PROP. LINE �G <br /> DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES L ; <br /> FOUNDATION <br /> AGRICULTURE WELL�— OTHER WELL PITS/SUMPS <br /> AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE _TYPE OF WELL PROBLEMr <br /> n Industrial ❑ Open Bottom C] Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing Specifications <br /> Domestic/Private w4ravol Pack 0 Tracy Type of Grout <br /> [� Public I-1 0 er ❑ Delta Depth o! Grout Seal <br /> CJ irrigation ', 4WApprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U I Type of Pump H"P•Sealing Material i Depth State Work Dona_ <br /> Well Destruction [ Welt Diameter Filler Materiel & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION LT DESTRUCTION GI availabe within 200 septic system permitted if public sewer is <br /> initallation will serve: Residence Commercial Other - <br /> Number of.living units: Number of bedrooms- `- <br /> Character of soil to s depth of 3 feat: Water table depth <br /> ' Capacity Na. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. C � �.:,� Method of Disposal <br /> k t Distance to nearest: -Well Foundation Property Line <br /> f LEACHING LINE 0 No. & Length of lines <br /> -Total length/size <br /> FILTER BED I-) Distance,to nearest:. ,i .Well Foundation Property Line <br /> I' SEEPAGE PITS ' I I Depth Size, t 1_" Number. <br /> SUMPS ' *L1_-Distance toM1nearest- Well ` FoundationProperty Line <br /> DISPOSAL PONDS © � - .='• ^ -'-' •. <br /> r - <br /> l I hereby certify that I have prepared this applicatio Arid the"t"the work"will be done in accordance with San.Joaquin county ordinances, state laws, and <br /> f <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies.the foilowing:_r.l certity.lhat 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 compensati;Oaws of California." Contractor's hiring of sub-contracting signature <br /> certifies the following: "I certify that in the part ormanca of the work fol which this permit is issued, I shall employ persons subject to workman'a compenss- <br /> tlon laws of California." ` <br /> The applicant r uire Complete dr win=g on-re ver <br /> Date: <br /> Signed <br /> DEPARTMENT USE ONL <br /> �r Date Area <br /> Application Accepted by <br /> r�: q -q o .. �. f� Dae 1.[. <br /> Pit or Grout speetion by _Date Fine Inspection by <br /> 41 <br /> Additional Comments, 4 r <br /> NA <br /> I <br /> Applicant - Return all copies to: S JOAQUIN COUNTY PUBLIC HEALTH 3ERVICHS�' <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES5201 I►NEr 1�/ Ff <br /> 445 N SAN JOAQUIN. ,'O B4OX,2o09i .STUCKTON, CA <br /> ,* .moi r .-. \ f' <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH UK 4 RECEIVED BY DATE PERMIT NO. <br /> INf0 Ivy ^ �(,'7 <br /> . Em 13•24IREV.I/NSI ! 3 _f'� <br /> EK 11.20 <br />